01 Conceptualización y Evaluación

Mindfulness- and AcceptanceBased Behavioral Therapies in Practice
Lizabeth Roemer Susan M. Orsillo
Series Editors Note by Jacqueline B. Persons
T ! "#$L%OR& PR!SS 'e( )or* London
ONE
An Acceptance-Based Behavioral +onceptualization of +linical Problems
Ma,a- a colle.e student- came to therap, because she (as e/periencin. intense an/iet, that (as ma*in. it difficult for her to .et her school assi.nments done and ta*e e/ams. She reported (orr,in. that she (ould fail out of school and never be able to support herself or help support her a.in. parents. She described herself as an an/ious person and sa( her an/iet, as evidence that she (as 0(ea*.1 Ma,a recounted numerous methods and strate.ies she had tried to ma*e herself feel less an/ious and more self-confident. Althou.h she described some periods of her life durin. (hich she felt better- overall she felt as if her attempts to control her an/iet, had failed. 2hen as*ed about avoidance- Ma,a (as able to .ive man, e/amples of situations she avoided- such as callin. her parents because she *ne( the, (ould as* about school. 2hen as*ed about her social life- she described not havin. time to ma*e friends because she needed to spend time on her school(or*- and it too* her so lon. to .et it done. #pon further 3uestionin.- she also noted that she 0felt uncomfortable1 (hen she (as (ith .roups of people- (hich also contributed to her avoidance of socializin.. Ma,a said she (as so bus, (ith school(or* that she did not have much time to feel lonel, or sad- althou.h- upon 3uestionin.- she (as able to recall times she had briefl, felt this (a, (hen she (asn4t 0*eepin. herself bus,.1 She also described periods of bin.e eatin. follo(ed b, restricted eatin.. Ma,a (anted to reduce her bin.e eatin. but sa( her restricted eatin. as one of her fe( stren.ths. Our treatment of Ma,a (ould be.in b, developin. an understandin. of ho( her e/periences and behaviors are lin*ed and understandable- even thou.h the, ma, seem compartmentalized and confusin. to her. 2e (ould collaborate (ith Ma,a in developin. a conceptualization and use it as a foundation for desi.nin. an individualized treatment plan5 it (ould be based in the overarchin. conceptual model that underlies acceptance-based behavioral approaches to treatment and is presented in this chapter.
&efinin. this underl,in. model is critical because the model serves as the foundation for an individualized formulation of a particular client4s difficulties. The model also
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M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' PRA+T$+!
provides a startin. point from (hich (e choose specific assessment strate.ies and clinical methods and a touchstone to (hich (e return repeatedl, to evaluate the course and pro.ress of therap,. The model contains three main elements- each of (hich relates to the others. %irst- clinical problems are seen as stemmin. from the (a, that clients :and humans in .eneral; often relate to their internal experiences. This relationship can be characterized as 0fused1 : a,es- Strosahl- < 2ilson6===;- entan.led :"ermer- >??@;- or 0hoo*ed1 :+hodron- >??7; and is distin.uished b, an overidentification (ith one4s thou.hts- feel- in.sima.es- and sensations. $n other (ords- ever,one feels sad from time to time- but a client (ho is fused (ith her internal e/perience ma, define herself b, that sadness5 for e/ample- Ma,a defines herself as 0(ea*1 due to her an/iet,. This overidentification or fusion (ith internal e/periences can set off a cascade of problematic responses. An/iet, is no lon.er vie(ed as a natural emotion that ebbs and flo(s5 instead- it is seen as a definin. or all-encompassin. state- (hich can lead to it bein. Aud.ed and vie(ed as intolerable and unacceptable. The second element of the model is experiential avoidance- or emotional- co.nitive- and behavioral efforts to avoid or escape distressin. thou.htsfeelin.s- memories- and sensations : a,es- 2ilson- "ifford- %ollette- < Strosahl- 6==B;. +lients en.a.e in e/periential avoidance hopin. to improve their lives- but it often parado/icall, leads to further distress or diminished 3ualit, of life :e...a,es et al.- 6==B;. !/periential avoidance is closel, tied to the (a,s clients relate to their internal e/periences. $f a client is fused (ith an emotion and sees that emotion as potentiall, over(helmin. and dan.erous- he or she ma, be hi.hl, motivated to en.a.e in strate.ies aimed at avoidin. or chan.in. that internal e/perience. $n Ma,a4s case- (henever she e/periences an/iet,- she vie(s it as a reflection of her inherent (ea*ness- is threatened b, it and tries to .et rid of it- but her efforts often fail- further fuelin. her sense of herself as (ea*. Self-monitorin. reveals that Ma,a eats to soothe her an/iet, but then e/periences more an/iet, due to fears of (ei.ht .ain- (hich she tries to control b, restrictin. her eatin.. Thus- both of these behaviors seem to serve an e/perientiall, avoidant function. The final element of the model is behavioral restriction or constriction- (hich occurs (hen individuals (ho are stru..lin. (ith internal e/periences fail to en.a.e in actions consistent (ith (hat matters most to them :i.e.- valued action5 2ilson < Murrell- >??C;- further perpetuatin. their distress and dissatisfaction. 2hen internal e/periences are ne.ativel, Aud.ed and seen as dan.erousaction is motivated more b, an attempt to avoid unpleasant states than b, a desire to en.a.e in fulfillin. behaviors. Ma,a has come to avoid man, aspects of social support- includin. bein. (ith friends and tal*in. to her parents- because she commonl, e/periences an/iet, in these conte/ts. er occasional feelin.s of sadness ma, si.nal that she is not livin. her life in a (a, that is meanin.ful and satisf,in. :i.e.- values-consistent;- ,et she avoids these feelin.s b, (or*in. hard- further perpetuatin. the c,cle. Acceptance-based models have been presented in detail b, several clinical theo- ristsDresearchers- such as a,es- Strosahl- and 2ilson :6===;5 Linehan :6==Ea;5 Se.al and collea.ues :>??>;5 and Facobson and +hristensen :6==B5 see a,es- %ollette- < Linehan>??C- for a boo*-len.th revie(;. $n this chapter- (e :6; dra( to.ether
+onceptualization of +linical 6 Problems = elements of these approaches- as (ell as traditional co.nitive-behavioral
approaches- to hi.hli.ht (hat (e consider the central elements of an acceptance-based behavioral conceptualization- :>; briefl, revie( some of the research that supports this model- and :E; illustrate ho(
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this model can be applied to specific clinical problems. 2e conclude (ith an overvie( of ho( this model translates into intervention and continue in the ne/t t(o chapters (ith discussion of ho( this model .uides individual treatment plannin.- assessment- and deliver,. Our approach to understandin. problematic clinical behaviors is based in a behavioral conceptualization. That is- (e understand responses to be learned throu.h both associations and conse3uences- and (e (or* to identif, the function of problematic responses to determine strate.ies for intervention. 2e see human difficulties as arisin. from a combination of biolo.ical predispositions- environmental factors- and learned habits that lead to a host of reactions and behaviors that occur automaticall,- (ithout a(areness or apparent choice. Learnin. happens in several (a,s. 2e can learn throu.h direct experience. %or instance- a (oman (ho (as raped mi.ht learn an association bet(een the smell of specific colo.ne and dan.er- (hich motivates her to avoid others (ith that same scent. 2e also learn throu.h conse3uences that consistentl, follo( particular behaviorseither reinforcin. or punishin. them and- thus- alterin. their fre3uenc,- as (hen an individual continues to drin* e/cessivel, because of the stressrelievin. properties of alcohol. Learnin. also occurs throu.h modeling and observation- such as seein. the reactions and behaviors of our parents or siblin.s- and throu.h instruction- such as bein. told to act in certain (a,s or not to sho( certain emotions. These learned patterns of behaviors often serve a useful function- particularl, in the short term5 ho(- ever- as conte/ts chan.e or ne( behaviors become available to us- certain patterns ma, no lon.er serve us (ell. This is particularl, the case (hen (e have come to respond infle/ibl, :i.e.- havin. the same response in a (ide ran.e of conte/ts;. %or instance- (e mi.ht learn from our famil, to 0put on a happ, face1 (hen (e feel distressed- and this behavior mi.ht be adaptive if our parents punish us an, time (e displa, sadness or an.er- such as throu.h criticism or inattention. o(ever- overlearnin. this response :i.e..- doin. it ri.idl, and infle/ibl,; is t,picall, maladaptive. Mas*in. our distress in a romantic relationship could interfere (ith the development of true intimac, or leave us unable to clearl, e/press our needs and desires. 2e mi.ht even learn to mas* our distress so 3uic*l, and consistentl, that (e lose a(areness of our o(n emotional state- (hich limits our abilit, to benefit from the function of emotions. A central problem- then- is the habitual- insensitive :to conte/t;- and automatic nature of these responses. %rom an acceptance-based behavioral model- three t,pes of habitual responses are seen as clinicall, important tar.ets for intervention. %irst- learned 3ualities of a(areness :particularl, a(areness of internal e/periences; are seen as both a cause and a conse3uence of clinical problems and an important focus of treatment. A(areness can be severel, diminished :a common feature of automatic respondin.;- narro(l, focused on unpleasant cues and events- or Aud.mental and critical. Second- the e/perientiall, avoidant function of man, overlearned behaviors can be problematic. That is- clinicall, relevant behaviors such as avoidin. certain situations- alcohol useovereatin.- and .eneral inaction ma, be maintained specificall, because the, serve the function of temporaril, reducin.- eliminatin.- or avoidin. distressin. thou.hts- feel- in.s- or sensations. %inall,- the shift a(a, from en.a.in. in actions that are of value to the individual :and sometimes to(ard
+onceptualization of +linical > Problems 6 impulsivel, and automaticall, en.a.in. in actions that are not valued- due
to their e/perientiall, avoidant function;- is thou.ht to contribute to distress and diminish 3ualit, of life.
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RESTRICTED, ENTANGLED, FUSED INTERNAL AWARENESS Limits in Internal Awareness

Man, clinical theories hi.hli.ht the potential role of deficits in internal- or e/periential- a(areness in ps,cholo.ical difficulties and the role of increased a(areness in promotin. ps,cholo.ical (ell-bein..6 +onsistent (ith these models- from an acceptance-based behavioral perspectivedeficits in a(areness ma, manifest in several (a,s that indicate clinical problems :these different (a,s ma, co-occur in the same individual;. %irstcli- ents are often unaware of their internal e/periences- not reco.nizin. emotional- co.nitive- or ph,siolo.ical responses that precede problematic behaviors :e...- ale/ith,mia;. +lients ma, also misunderstand their internal responses- labelin. ph,siolo.ical sensations as hun.er (hen the, in fact reflect distress or mista*in. one threatenin. emotion :such as an/iet,; for another- more personall, acceptable one :such as an.er;. &imin- ished or inaccurate a(areness reduces clients4 abilit, to use their emotional responses functionall, and ma, lead them to react in (a,s that are puzzlin. to them. %or instance- a chronicall, lonel, client ma, tell ,ou that he does not attend social events because he does not enAo, them- (hen- in fact- he is avoidin. them due to his unreco.nized an/iet, and (ould ver, much li*e to be more sociall, en.a.ed. Another client ma, surprise herself b, respondin. a..ressivel, to a co(or*er because she did not realize she had felt resentment and an.er due to her co(or*er 4s repeated apparent sli.hts and disre- spectful tone. Althou.h Ma,a (as ver, a(are of her an/ious internal e/periences- she had more trouble noticin. and identif,in. her e/perience of sadness- so that she (as not conscious of the (a,s her life (as unsatisf,in. to her. $n sum- individuals ma, either avoid or en.a.e in undesired behaviors due to their lac* of emotional a(areness- and this impaired a(areness ma, interfere (ith individuals4 abilit, to choose to act rather than react to situations. Lac* of emotional a(areness- li*e man, clinicall, relevant characteristics- is prob- abl, learned. $ndividuals ma, be tau.ht b, their parents to distrust their emotional reactions- such as (hen a parent tells a child not to be afraid in a threatenin. situation or dismisses feelin.s of sadness over a loss or disappointment :Linehan- 6==Ea;. $f a parent habituall, responds to a child in this (a,- the child ma, come to rel, on e/ternal sources to 0*no(1 ho( he or she is feelin. in a particular situation. +hildren ma, be punished for bein. 0emotional1 and re(arded for bein. 0rational-1 or 0calm- cool- and collected-1 (hich teaches them to i.nore their internal e/periences in the hope that ne.ative emotions (ill pass.
Difficulties with the Awareness
ualit! "f Internal
+lients (ith limited a(areness of the nuances of their emotions can also simultaneousl, report a hei.htened a(areness of their .eneral distress(hich can be confusin. to them and their therapists. %or instanceindividuals (ith panic disorder are h,pera(are of their ph,siolo.ical sensations- individuals (ith .eneralized an/iet, disorder :"A&; are painfull, a(are of their (orr,- and individuals (ith depression are ver, a(are of their
+onceptualization of +linical > 6 Problems E &arren olo(*a- in his dissertation- su..ests that e/periential a(areness ma, be a common
factor across diverse forms of ps,chotherap, : olo(*a- >??85 olo(*a < Roemer- >??7;.
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ne.ative mood state5 ho(ever- this a(areness differs si.nificantl, from the a(areness that ps,chotherap, aims to cultivate. %irst- this a(areness ma, not be clear- in that individuals ma, perceive the, are .enerall, distressed but not be able to pinpoint specific and subtle shifts in their emotionalph,siolo.ical- or co.nitive state. %or instance- a client mi.ht describe a panic attac* that lasted > (ee*s :(hich is not ph,siolo.icall, possible; or feelin. 0bad-1 (ithout a clear sense of (hether he feels sadness- an.erfear- or a blended emotion. $ndividuals4 a(areness ma, be critical !udgmental- or reactive. %or instance- a client (ith recurrent depressive episodes mi.ht notice her sadness and be ver, distressed that she is sad a.ain- thin* her sadness is a si.n that a debilitatin. depression is returnin.and feel alarmed b, its occurrence. These reactions li*el, perpetuate and (orsen the sadness- possibl, leadin. to depression- rather than promotin. adaptive functionin.. Ma,a provides an e/ample of this *ind of 3ualit, of a(areness. She (as ver, a(are of an, si.ns of an/iet, and responded to them (ith self-Aud.ment and criticism- further perpetuatin. her an/iet,. A(areness can also become narrowed- or selective. %or instanceindividuals (ith an/iet, disorders ma, be so a(are of a potential threat that the, do not notice other cues in their environment that si.nal safet,- or the, ma, be so focused on their an/ious respondin. that the, do not detect the occurrence of positive emotional responses. This selective attention to an/iet, further e/acerbates their sense that their an/iet, is unchan.in. and pervasive. All of these e/amples of (a,s in (hich the 3ualit, of e/periential a(areness can be problematic can be thou.ht of as aspects of a lar.er cate.or, of overidenti"ication- or 0"usion1 : a,es- Strosahl- < 2ilson- 6===; or 0entanglement1 :"ermer- >??@;- (ith one4s internal e/perience in a (a, that inhibits adaptive functionin.. &ifferent acceptance- based approaches use different terms to identif, this 3ualit, and emphasize some(hat different aspects of it- but the, share a conceptualization of this 0hoo*ed1 relationship as a source of sufferin. or clinical problems and an important tar.et of intervention. These models are consistent (ith traditional behavioral models of 0fear of fear1 :"old- stein < +hambless- 6=78;distress about emotions> :2illiams- +hambless- < Ahrens6==7;- interoceptive conditionin. :e...- Barlo(- >??>;- co.nitive theories of an/iet, sensitivit, :e...- Reiss- Peterson- "urs*,- < Mc'all,- 6=8B;- and metaco.nitive beliefs :e...2ells- 6==@;- each of (hich su..ests that ne.ative reactions to or appraisals of internal e/periences e/plain ho( these e/periences pro.ress from natural human responses that ebb and flo( to more ri.id patterns of problematic respondin.. Althou.h a detailed discussion of these models is be,ond the scope of this boo*- some are hi.hli.hted due to their potential utilit, in clinical formulations.
Reactivity to and Judgment of Internal Experiences

Man, models of clinical problems note that internal responses become problematic due to individuals4 reactions to these responses rather than the responses themselves :e...-
+onceptualization of +linical > > Problems @ Althou.h the terms "ear o" "ear and "ear o" emotion have been used in the literature- these
concepts are more accuratel, labeled 0an/iet, of1 or 0distress about1 fear and other emotionsin that the, describe an anticipa- tor, or reactive process (ith a lon.er duration than fear :Barlo(- personal communication5 see Barlo(- 6==6- for a discussion of the role of an/iet,Dd,sth,mia in response to the e/perience of basic emotions in emotional disorders;.
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Barlo(- 6==65 Bor*ovec < Sharples- >??C;.E 2hile a (hole ran.e of internal responses ma, naturall, come and .o for all of us- humans have also developed an abilit, to respond to these e/periences in certain (a,s that ma, lead them to become more ri.id- 0stic*,-1 or infle/ible- resultin. in clinical problems. %or instance- models of panic note that panic attac*s are common across the population- but onl, some people develop panic disorder- and these seem to be the individuals (ho e/perience an/ious apprehension about future panic attac*s :Barlo(- 6==6;. Relatedl,behavioral models su..est that individuals (ith panic disorder have learned to e/perience an/iet, in response to their bodil, sensations :interoceptive conditionin.5 Barlo(- >??>;. This distress or apprehension seems to be the crucial element of panic disorder- and successful treatments tar.et it directl,5 successfull, treated individuals continue to e/perience panic sensations but no lon.er e/perience hei.htened an/iet, in response to these sensations. The reactive a(areness of bodil, sensations that characterizes individuals (ith panic disorder is also narro(ed- so that the, focus solel, on arousal sensations and ma, have limited emotional a(areness. %or instance- a recent stud, found that individuals (ho reported a hi.h level of panic s,mptoms reported more ne.ative emotional responses and more emotional avoidance efforts in response to a positivel, valanced film clip than did individuals not prone to panic :Tull < Roemer>??7;5 thus- these individuals ma, respond to all *inds of arousal s,mptoms (ith an/iet, rather than discriminatin. bet(een sources of that arousal. Acceptance-based models that emphasize mind"ulness :a construct dra(n from Buddhist traditions but used in secular conte/ts for health promotion and intervention purposesGe...- Habat-Iinn- 6==?5 Se.al et al.>??>;- (hich has been defined as 0open- hearted- moment-to-momentnon-Aud.mental a(areness1 :Habat-Iinn- >??@- p. >C;- similarl, emphasize the si.nificance of reactions to one4s e/periences- hi.hli.htin. the role that Aud.mental- critical a(areness ma, pla, in human sufferin. or clinical problems. Often- clients present (ith habitual Aud.ments of themselves or their responses as bein. 0(ea*-1 0craz,-1 0irrational-1 or 0stupid.1 As the, notice their internal e/periences- the, react (ith critical Aud.ments- promptin. efforts to avoid these e/periences. These Aud.ments ma, stem from the (a, care.ivers responded to them .ro(in. up. $n fact- clients are often able to reco.nize that the critical (ords the, use to describe their responses are the same (ords a parent habituall, used in criticizin. them. These Aud.ments ma, also stem from- or be perpetuated b,- the perception that others do not seem to have the same internal reactions :because the, cannot observe others4 internal e/periences;. Ma,a ma, not reco.nize that her friends and famil, also e/perience an/i- et, in certain conte/ts. She ma, have heard her parents or others refer to people (ho e/pressed an/iet, as 0(ea*-1 leadin. her to vie( her o(n an/iet, that (a,. This *ind of Aud.ment is li*el, to *eep her from sharin. her e/periences of an/iet, (ith others- (hich (ill also *eep her from learnin. that others have similar e/periences. Althou.h clients often report beliefs that this *ind of self-critical stance helps motivate them to chan.e- it seems more li*el, that this perspective contributes to distress and impairment. Linehan4s :6==Ea; classic model of borderline personalit, disorder hi.h- li.hts the etiolo.ical role of an invalidatin. environment on subse3uent d,sre.ulated
+onceptualization of +linical Problems

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+hristensen and Facobson :>???; note a similar process in couples. The, distin.uish bet(een initial problems :such as a difference in desired fre3uenc, of se/ual activit,; and reactive problems :the difficulties that emer.e from each member of the couple4s attempts to cope (ith this problem- such as hostilit,- (ithdra(al- and accusation;.
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emotion- co.nition- and behavior. $ndividuals then learn to invalidate their o(n e/perience- further contributin. to their d,sre.ulation. The presence of a Aud.mental- self- critical stance :and the absence of self-compassion; can be seen as a causal or maintainin. factor in a (ide ran.e of presentin. problems :see 'eff- Rude- < Hir*patric*- >??7- for evidence of association bet(een self-compassion and ps,cholo.ical (ell-bein.;. %or instance- (hen individuals feel sad and become critical of their responses- this ne.a- tive vie( of themselves ma, decrease their motivation to ma*e behavioral chan.es or en.a.e full, in their lives. $ndividuals (ith social an/iet, commonl, en.a.e in self- Aud.ment that ma, e/acerbate their fears of others4 Aud.ments- reduce their (illin.ness to en.a.e in various actions (hen the, ma, be Aud.ed- and increase their sense of bein. unsafe in the (orld due to some *ind of personal failin.. Ma,a4s criticisms of herself for e/periencin. an/iet, e/acerbate her fears that she (ill be unsuccessfulhei.htenin. rather than lessenin. her an/iet,.
Entangled Awareness
or
Fused
Broadl,- acceptance-based models that emphasize mindfulness hi.hli.ht a 3ualit, of a(areness that leads to sufferin. and contrast it (ith a 3ualit, of a(areness that can be more freein.. Accordin. to these models- (e commonl, become 0hoo*ed1 into our internal e/perience- partl, b, seein. it as more indicative of realit, than it is and partl, b, Aud.in. it and disli*in. it and (antin. it to be other than it is. Thus- rather than Aust e/periencin. an.er- (e have an.er- a disli*e of an.er- and a (ish for an.er to .o a(a,.C Rather than e/periencin. a fearful response- (e define ourselves as a fearful person. Parado/icall,- these responses hoo* us more to the ver, emotions (e are tr,in. to avoid. 2ishin. internal e/periences (ere other than (hat the, are is natural.iven ho( unpleasant certain emotional- co.nitive- or ph,siolo.ical reactions can feel and our common socialization e/periences :e...- bein. told- 0don4t (orr,- be happ,1;.@ )et this desire for our internal e/periences to be other than the, are- particularl, (hen (e attach to it and act from itis thou.ht to increase their unpleasantness (ithout diminishin. the e/periences themselves. a,es- Strosahl- and 2ilson :6===; describe a similar process in their description of clean versus dirty emotions. +lean emotions are those (e have in response to an event- (hile dirt, emotions arise from our stron. desires and efforts to ma*e clean emotions .o a(a,(hich onl, add to our distress. The human tendenc, to mista*e transient internal e/periences for indications of permanent truth or realit, is a li*el, cause of or contributin. factor to these desires to feel or thin* other than (e do. %or instance- if (e feel an/iet, about an upcomin. presentation and have the thou.ht that (e are not capable of doin. it- (e ma, ta*e that thou.ht as an indication that (e cannot do the presentation. 2hen (e feel hurt b, a comment from our partner and have the thou.ht that she does not reall, care about usC
Shame in response to an.er or other emotional reactions to environmentall, elicited emotions are e/amples of (hat "reenber. and Safran :6=87; refer to as secondar, emotionsor emotions that occur in response to adaptive primar, emotions. The, su..est these t,pes of emotional responses are particularl, important tar- .ets of therapeutic intervention.
+onceptualization of +linical > @ Problems Mindfulness-based models similarl, note the (a,s that approachin. e/ternal events = b,
Aud.in. or (ishin. the, (ere other(ise leads to sufferin.. 2e discuss this aspect of mindfulness in the section on behavioral constriction.
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(e ma, ta*e this as an indication of her true- lastin. feelin.s. +onversel,(e ma, ta*e our o(n transient e/perience of an.er to(ard and absence of affection for our partner as an indication of our true feelin.s and fear that the relationship is over. 2hen (e e/perience sadness and consider ourselves defined b, this e/perience- (e can develop a sti.matized sense of ourselves as dama.ed. This fusion bet(een our e/perience and our perception of realit, ma*es internal e/periences particularl, po(erful and li*el, underlies our desire for them to be other than the, are. $f the thou.ht that our partner does not reall, care about us (ere Aust a thou.ht- that (ould arise and fall naturall, and did not necessaril, reflect realit,- it (ould not be so aversive and distressin..B a,es and collea.ues :e...- a,es- Strosahl- < 2ilson- 6===; have (ritten e/ten- sivel, about the role that co.nitive fusion ma, pla, in ps,cholo.ical problems and the process throu.h (hich this fusion develops. Relational frame theor, :R%T5 a,es- Barnes- olmes- < Rosche- >??6; su..ests that humans continuall, derive relations amon. events- (ordsfeelin.s- e/periences- and ima.es as (e en.a.e (ith our environ- mentinteract (ith others- thin*- observe- and reason. These relations result in internal stimuli :e...- ima.es- feelin.s- thou.hts- memories; ta*in. on the functions of the events to (hich the, are lin*ed. That is- a memor, of a painful event can elicit the same reactions as the event itself- and thou.hts and feelin.s can provo*e reactions comparable to the e/ternal conte/ts (ith (hich the, have been paired. Relational learnin. has an adaptive component. %or instance- it allo(s us to ima.ine situations in order to antici- pate our potential reactions to them and ma*e choices (ithout havin. to actuall, e/perience each option before us. 2e can describe our e/periences to another person- and that person can vicariousl, ima.ine our subAective e/perience. $n these (a,s- (e can learn far be,ond our direct e/perience- increasin. our potential and fle/ibilit, e/ponentiall,. Relational learnin. also sets the sta.e for fusion bet(een internal e/periences and the events the, reflect- such that internal e/periences come to elicit an/iet,sadness- an.er- or distress- as if the events themselves (ere actuall, happenin.. This fusion can prompt e/periential avoidance- similar to the modern learnin. theor, of panic described above- in (hich interoceptive conditionin. :i.e.- conditionin. to internal sensations; leads bodil, sensations to be associated (ith an/iet, and distress- resultin. in panic disorder. The responses themselves are not problematic- but a fused e/perience of them is. The an/iet, Ma,a e/periences around her school(or* or in social situations is not problematic on its o(n- but her reactions to an, an/iet, s,mptoms that arise ma*e the an/iet, more distressin. and pervasive- creatin. difficulties for her. %usion or entan.lement has been identified as an important component in depressive relapse. Se.al and collea.ues :>??>; su..est that depression results from learned patterns of ne.ative thin*in. and ruminative response st,les activated b, a ne.ative mood state. These habits of processin. information feed on themselves- droppin. mood lo(er and lo(er and ma*in. it more difficult to recover. The inabilit, to see thou.hts as Aust thou.hts :in other (ords- to step bac*- or decenter- from these thou.ht processes and observe them; is a *e, element of this depressive spiral. ObAective a(areness at
+onceptualization of +linical E B Problems 6 or $t is important to note that thou.hts do not have to be clearl, false for de"usion
decentering to be beneficial. 2hile models underl,in. co.nitive therap, often su..est that the irrationalit, of thou.hts is central to clinical problems- acceptance-based models emphasize the problematic nature of relatin. to thou.hts in a specific (a,- ta*in. them as unchan.in. realities rather than reactions to a .iven moment. $n this conte/t- a fused relationship to a thou.ht that accuratel, reflects a momentar, realit, (ould still be problematic in that it (ould preclude a fle/ible- choice-based adaptive mode of respondin..
E >
an, point (ould help alter the traAector, and allo( for more fle/ibilit, in behavioral respondin.. Thus- in this model- critical ne.ative a(areness characterizes depression and the absence o" a more decentered disentangled a(areness of this ne.ative thou.ht process perpetuates it. Studies have found that successful co.nitive therap, increases this decenterin. :Teasdale et al.- >??>;- su..estin. it ma, be an active in.redient in both co.nitive and acceptance-based behavioral interventions.
E#$ERIENTIAL A%OIDANCE
One of the most clinicall, relevant conse3uences of a fused- entan.led relationship (ith internal e/periences is that it is li*el, to lead to ri.id efforts to alter or avoid internal e/periences- or experiential avoidance. a,es- Strosahl- and 2ilson4s :6===; seminal (or* on the role of e/periential avoidance in clinical problems provides an important cornerstone for acceptance-based behavioral models. $n hi.hli.htin. the importance of considerin. the function- rather than the form- of clinical presentations- a,es and collea.ues su..est that man, diverse clinical problems can be understood as servin. the function of e/periential avoidance. Behaviors such as substance abuse and deliberate self-harm and s,mptoms such as (orr, or rumination ma, all be strate.ies aimed at alterin. the form or fre3uenc, of internal e/periences :thou.htsfeelin.ssensations- ima.es;. That is- these are all :ultimatel, unsuccessful; attempts to reduce or eliminate un(anted- distressin. internal e/periences. These avoidance efforts often seem to have parado/i- cal effects- resultin. in increases in both the tar.ets of avoidance :e...- the un(anted thou.htsfeelin.s- or sensations; and more .eneral ps,cholo.ical distress :for revie(s- see Purdon- 6===5 Salters-Pedneault- Tull- < Roemer- >??C; and interferin. (ith 3ualit, of life. Sometimes these effects occur in different channels of respondin.. %or instance- in one e/periment- instructin. participants to conceal their emotional e/pression (hile (atchin. an emotional film clip resulted in a parado/ical increase in ph,siolo.ical activation :"ross < Levenson- 6==E- 6==7;. People can easil, become stuc* in a c,cle- (ith their efforts to avoid distress actuall, increasin. it and fuelin. further avoidance efforts. A host of studies have demonstrated si.nificant relationships bet(een reports of e/periential avoidance and reports of a (ide ran.e of clinical problems :see a,es- Luoma- Bond- Masuda- < Lillis>??B- for a revie(;- and e/perimental studies have sho(n that individuals instructed in e/periential acceptance demonstrate reduced subAective distress follo(in. laborator, stressors compared to those (ho are instructed in e/periential suppression :e...- !ifert < effner- >??E5 Levitt- Bro(n- Orsillo< Barlo(- >??C;. Ma,a reported intense efforts to *eep others from reco.nizin. her an/iet,- (hich ma, have hei.htened her arousal and distress. She also described tr,in. to push an/ious thou.hts out of her head but findin. that the, fre3uentl, returned even more intensel,. !/periential avoidance efforts are li*el, robust and difficult to chan.e for man, reasons. %irst- e/perientiall, avoidant responses are often initiall, ne.ativel, rein- forced b, an immediate reduction in distress. That is- actions aimed at reducin. distress li*el, lead to an initial reduction in distress- and this removal of an un(anted stimulus increases the fre3uenc,
+onceptualization of +linical E Problems of the behavior that preceded it. A commonl, held understandin. E of
e/cessive substance use provides a particularl, salient e/ample of this process :e...- Marlatt < 2it*ie(itz- >??@;. Althou.h substance use can have numerous apparent ne.ative conse3uences in the lon. term- it t,picall, results in an initial mood shift that
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is e/perienced as pleasant and stress reducin.. This conse3uence is hi.hl, reinforcin.- particularl, for individuals (ho e/perience a .reat deal of distress andDor have particularl, ne.ative reactions to their distress. Thusthe behavior is li*el, to continue- althou.h its lon.-term conse3uences :e...disruptions in relationships and other areas of functionin.- hei.htened tolerance- (ithdra(al s,mptoms in the absence of use- and the failure to effectivel, process or resolve the distress that is habituall, avoided; all perpetuate and increase distress. Similar models have been presented for restricted eatin. :e...- effner- Sperr,- !ifert- < &et(eiler- >??>; and deliberate self-harm :+hapman- "ratz- < Bro(n- >??B;. Ma,a4s pattern of both bin.ein. and restrictin. her eatin. fits this model. She describes an initial reduction in an/iet, (hen she eats e/cessivel,- but her an/iet, increases as she be.ins to (orr, about her (ei.ht. She then restricts her food inta*e- a.ain lo(erin. her an/iet, but ma*in. her emotionall, vulnerable due to reduced nutrition- increasin. her ris* of becomin. distressed and overeatin. a.ain. $n addition to the natural conse3uences that serve to maintain and perpetuate e/perientiall, avoidant strate.ies- social forces li*el, maintain these strate.ies as (ell. Althou.h several ps,cholo.ical :e...a,esStrosahl- < 2ilson- 6===5 Ma,- 6==B; and Buddhist :e...- +hodron- >??6; theorists have noted the ubi3uit, of emotional pain- (e often .et the messa.e from other people that (e should be able to control our emotional distress throu.h sheer (illpo(er. Also- it can seem to us that others are successfull, avoidin. their emotional pain because (e do not have access to their e/perience. Ma,a commented that her peers and siblin.s do not e/perience the same an/ieties that she does- but she (as able to reco.nize that these individuals ma, also be una(are of her an/iet,- .iven her tendenc, to conceal it. $n addition- avoidance or escape behavior can be functional- ma*in. it harder for us to notice its ineffectiveness in reducin. internal distress. Avoidin. and escapin. threatenin. environmental conte/ts is evolutionaril, adaptive and functional- but our inabilit, to escape internal e/periences permanentl, :fueled b, our abilit, to ima.ine and remember; renders these same strate.ies futile- and- in fact- harmful (hen directed at internal responses. !/periential avoidance is also ubi3uitous because our fused- entan.led relationships (ith our internal e/perience naturall, motivate these efforts. $f an/ious sensations are e/perienced as e3uivalent to impendin. disaster and ne.ative thou.hts about ourselves are e/perienced as indicators of realit,- motivation (ill be ver, hi.h to avoid these sensations and thou.hts. $f- on the other hand- these e/periences are seen as ris- in. and fallin.- each no more true or permanent than the last- then the stron. ur.e and effort to avoid and escape them (ill be diminished. +onversel,- ever, attempt to avoid them ma, stren.then the dan.er associated (ith them- contributin. to the c,cle and promptin. further avoidance efforts. Research- theor,- and clinical observation su..est that e/periential avoidance ma, be a useful (a, to conceptualize a host of clinical presentations. $n addition to the behavioral s,mptoms described above that serve an e/perientiall, avoidant function- some common internal processes ma, also reflect efforts at e/periential avoidance. The avoidance model of (orr, :Bor*ovec- Alcaine- < Behar- >??C; posits that chronic e/cessive (orr, :repeatedl, considerin. potential ne.ative outcomes in the
+onceptualization of +linical E Problems @ future; ma, in part function to reduce ph,siolo.ical arousal. Althou.h (orr,
itself is a troublin. internal e/perience that individuals often (ant to .et rid of- studies have sho(n that (orr, actuall, serves a positive function b, reducin. ph,siolo.ical arousal in response to fearful ima.es or situations :e...- Bor*ovec < u- 6==?;. This ne.ativel, reinforcin.
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propert, of (orr, increases its fre3uenc,. People are li*el, to *eep (orr,in. because it has this relievin. ph,siolo.ical effect- even if the, are una(are of that effect. o(- ever- (orr, also perpetuates threatenin. associations b, interferin. (ith the complete processin. of feared events. Someone (ho is an/ious about socializin. (ith co(or*ers at lunch ma, decrease her arousal in this situation if she is preoccupied throu.hout lunch b, her (orries about an upcomin. dental appointment- but this prevents her from learnin. that- althou.h socializin. (ith collea.ues can elicit some feelin.s of fear- it can also be pleasant and fearful feelin.s diminish over time. Ruminative processes in depressed individuals ma, serve a similar function- reducin. deeper levels of sadness and pain but maintainin. .eneralized ne.ative mood states. +lients (ith a ran.e of clinical problems also en.a.e more purposefull, in efforts to avoid internal e/periences. %or instanceindividuals (ith obsessiveJcompulsive disorder describe their co.nitive rituals as a strate., that reduces distress in the moment- but the impairin. an/iet, and fear is maintained over time. +lients (ith posttraumatic stress disorder attempt to avoid thou.htsfeelin.s- and memories associated (ith the traumas the, have e/perienced. Althou.h the, ma, .ain some short-term relief from these efforts- the, find that the recollections return repeatedl,perhaps more often because of these efforts to push them a(a,. $ndividuals (ith substance dependence or abuse problems tr, to i.nore thou.hts and ur.es to use- onl, to find them returnin. more stron.l,. +ouples in distressed relationships ma, en.a.e in repeated efforts to push a(a, an.er- hurt- or (orr, in response to their partner- onl, to find these reactions return more intensel,. !/periential avoidance can also help e/plain clinical presentations (here avoidance is less obvious. %or instance- Toni and Fanelle described a pattern of interaction in (hich- durin. stress- Toni e/pressed an.er and irritation- (hile Fanelle (ithdre(- became 0numb-1 and e/pressed little emotion. Toni e/perienced Fanelle4s (ithdra(al as reAection- promptin. further an.er- (hile Fanelle e/perienced Toni4s an.er as threatenin.promptin. further (ithdra(al. &elvin. more deepl, into each partner 4s e/perience revealed that Toni first e/perienced an/iet, and fear of reAection. She found this vulnerabilit, threatenin. and avoided it throu.h an.er- lashin. out at Fanelle. er an/iet, (as hei.htened (hen Fanelle (ithdre(- promptin. further an.r, outbursts. Fanelle similarl, feared reAection and tried to reduce her distress b, (ithdra(in. and 0shuttin. do(n1 emotionall,5 her distress (as increased b, Toni4s an.r, behavior. This shared understandin. can help Toni and Fanelle cultivate empath, for one another :.iven the shared e/perience the, are havin.- despite ver, different behavioral manifestations5 Facobson < +hristensen- 6==B;. The, can then build from this shared understandin. to develop alternative (a,s to approach and respond to one another- at times toleratin. increased distress but eventuall, (or*in. to(ard a more effective resolution for both of them.
C"m&le'ities A("i)ance
"f
E'&eriential
!/periential avoidance is a *e, part of an acceptance-based behavioral
+onceptualization of +linical E Problems model because ri.id efforts at e/periential control appear to have a host 7 of
clinicall, relevant conse- 3uences- su..estin. it is a useful tar.et for intervention. Before describin. these conse- 3uences in more detail- it is important to note that- in certain conte/ts- efforts to modif, internal e/perience ma, not be problematic or harmful. #nfortunatel,- the apparent success of these strate.ies can fuel and maintain maladaptive efforts at internal control.
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S*illful application of acceptance-based behavioral therap, relies on a clear understandin. of the comple/ities of e/periential control and the conte/ts in (hich tr,in. to influence our internal e/periences mi.ht be beneficial versus harmful. $n man, cases- efforts to modulate our internal e/periences can be beneficial. %or instance- (e mi.ht focus on our breathin. prior to a public spea*in. en.a.ement and find it reduces our heart rate sli.htl,- allo(in. us to present material more effectivel, to our audience. On the other handthis focused breathin. ma, have no effect on our heart rate or even increase it. 2e mi.ht find that (e *eep thin*in. about a mista*e (e made at (or* or somethin. (e (ish (e had not said to a friend and choose to turn our attention to a movie or a boo* in an effort to reduce our rumination. This distraction mi.ht lead to some relief- or (e mi.ht find that our minds return to the event repeatedl,- re.ard- less of (hat (e tr, to brin. our attention to. $f (e are able to allo( for the possibilit, of any of these conse3uences of our behavior- there is no harm in en.a.in. in actions that mi.ht modulate or alter our internal e/periences. 2hen the, (or*- the, mi.ht allo( us to e/pand our a(areness- .ain additional perspectives- have ne( e/periencesand increase fle/ibilit,. $f (e can accept it (hen the, do not (or*- (e can continue livin. our lives (ith the internal e/periences (e (ere unable to alter. Problems can arise (hen (e be.in to tr, ri.idl, to eliminate or avoid distressin. internal e/periences and (hen this .oal becomes a prominent motivator of our behavior- either consciousl, or not :e/periential avoidance often becomes an automatic process;. These habitual- ri.id efforts are problematic in that the, :6; often do not (or*- :>; interfere (ith the function of emotional responses- :E; perpetuate a problematic relationship (ith internal e/periences- and :C; impair functionin.. As revie(ed aboveefforts to avoid or suppress our thou.hts or feelin.s are often unsuccessful and instead increase the tar.ets of suppression or avoidance. The, are most li*el, to be ineffective (hen (e most (ant them to (or*5 in fact- our efforts ma, (orsen our distress rather than ameliorate it. Ma,a4s e/perience stud,in. for e/ams hi.hli.hts this process. As she e/periences an/ious thou.hts and sensations- she tries to put them out of her mind- tellin. herself to focus on the material. She finds that the more she tries to calm herself and the more stron.l, she (ants the an/iet, to .o a(a,- the more an/ious and out of control she feels. This ma*es it harder for her to stud, effectivel,- further increasin. her an/iet,.
C"nse*uences A("i)ance
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Avoidance or suppression of naturall, occurrin. emotional responses :i.e.primary emo# tions- accordin. to "reenber. < Safran- 6=87- or emotions that stem naturall, and functionall, from a particular conte/t; can e/acerbate emotional distress and interfere (ith successful emotional processin.. !/tensive research on e/posure-based treatments for an/iet, disorders reveals the importance of clients e/periencin. their fear durin. e/posure to feared stimuli- so that the, can full, access their fearful associations and incor- porate ne(- nonthreatenin. associations :%oa < Hoza*- 6=8B;. %or instance- clients (ho displa, more intense facial fear
+onceptualization of +linical E Problems = e/pressions :%oa- Ri..s- Massie- < )arczo(er- 6==@; and those (ho report
hi.her subAective an/iet, ratin.s :reflectin. hi.her emotional en.a.e- ment5 Fa,co/- %oa- < Morral- 6==8; in the first session of e/posure therap, achieve better results from such treatment. Avoidance or distraction inhibits this ne( learnin. of non- fearful associations. Thus- e/periential avoidance is li*el, to maintain distress rather
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than allo( emotional responses to run their course and ne( learnin. to evolve. Ma,a4s pervasive an/iet, ma, result in part from her repeated efforts to suppress or limit her an/ious e/perience- (hich li*el, interfere (ith the natural ebb and flo( of her an/ious and fearful respondin. so that she does not e/perience the natural decline that (ould accompan, continued e/posure to threat cues. !/periential avoidance can also interfere (ith other aspects of the functional value of emotional responses. !motions provide important information re.ardin. our interaction (ith our environment- tellin. us (hen our needs are bein. th(arted- (hen a threat is present- or (hen (e have lost somethin. of value :e...- %riAda- 6=8B5 "reenber. < Safran- 6=875 Linehan- 6==Ea- 6==Eb;. Our emotional responses help us communicate our needs to others in the form of e/pressions that occur rapidl, and automaticall,. abit- ual- ri.id avoidance of our emotional responses is li*el, to interfere (ith our understandin. of our interactions (ith others as (ell as of our o(n needs and desires. %or instance- a client (ho is avoidin. his chronic feelin.s of sadness and disappointment b, distractin. himself (ith alcohol mi.ht be missin. the information this sadness can provide himsuch as his dissatisfaction (ith his current Aob and a need to e/plore (a,s to improve this situation or pursue another Aob. Similarl,- Ma,a4s constant focus on her (or* is *eepin. her from noticin. the sadness and loneliness that mi.ht motivate her to cultivate her social and familial relationships. !/periential avoidance can also affect our Aud.ments of or reactions to our internal a(areness. One stud, revealed that instructions to suppress specific thou.hts led to reports of increased an/iet, in response to these thou.hts :Roemer < Bor*ovec- 6==C;. Another found that individuals (ho (ere told to control ph,siolo.ical sensations rated their sensations as more distressin. than those (ho (ere encoura.ed to accept them- even thou.h the intensit, of the sensations (as similar across .roups :Levitt et al.>??C;. Repeated efforts to eliminate specific thou.hts- emotionssensations- and memories is li*el, to lead to increased ne.ative Aud.ments of these internal events (hen the, recur- promptin. hei.htened efforts to avoid them. $t is eas, to en.a.e in a c,cle in (hich reactivit, to internal e/periences leads to control efforts that increase reactivit, to these e/periences. Ma,a4s critical response to her an/ious s,mptoms is li*el, (orsened b, her repeated- unsuccessful efforts to reduce these s,mptomsma*in. them seem more threatenin. and pervasive. !/periential avoidance ma, also promote more critical reactions to our internal e/periences because it inhibits our abilit, to receive validation from others. A common strate., for avoidin. distress is to conceal our emotional responses. $n addition to the effect this ma, have on our ph,siolo.ical arousal :possibl, hei.htenin. it5 "ross < Lev- enson- 6==E;- mas*in. our distress ma*es it impossible for others to respond empathi- call, to our e/perience or share their o(n similar stru..les. !/ternal validation is one (a, to cultivate self-compassion :reco.nizin. the humanness of our responses;- (hile concealin. distress can hei.hten our sense that our stru..les are uni3ue- ma*in. it eas- ier to Aud.e and criticize these e/periences. !/periential avoidance also occludes and narro(s a(areness. Attempts to reduce and avoid distress are li*el, associated (ith a tendenc, to direct attention a(a, from internal e/periences. This lac* of attention can reduce
+onceptualization of +linical C Problems 6 the clarit, of one4s internal a(areness- ma*in. it harder to respond
effectivel,. %or instance- if Ma,a becomes an.r, at her parents after the, ma*e critical comments about her school performance but is uncomfortable (ith her an.er- she ma, onl, briefl, note her reaction and then shift her atten-
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tion to(ard internal and e/ternal efforts to avoid this e/perience of an.er. As a result- she (ill li*el, continue to feel activated and reactive in some (a,- but she ma, no lon.er be a(are of (hat prompted this reaction. She ma, misinterpret her response as more an/iet,- (hich could hinder her abilit, to chan.e the situation that elicited her an.er. Thus- reducedlimited- or 0mudd,1 internal a(areness ma, be a result of habitual e/periential avoidance. %inall,- e/periential avoidance often leads to behavioral avoidance or behavioral en.a.ement that interferes (ith individuals4 broader functionin.. $n addition to the more obvious costs :behaviors such as substance useovereatin.- or self-harm;- e/periential avoidance can subtl, impact behavior b, preventin. individuals from en.a.in. full, in their relationshipspursuin. careers (ith meanin. to them- or effectivel, dealin. (ith stressful life conte/ts. A.ain- ri.idit, is the central problemGefforts to reduce distress ma, promote functionin. in man, conte/ts- but ri.id avoidance efforts at the e/pense of life-enhancin. .oals ma, lead to restricted- unsatisf,in. lives.
+E,A%IORAL CONSTRICTION FAILURE TO ENGAGE IN %ALUED ACTION

Acceptance-based behavioral models focus particularl, on the behavioral costs of e/periential avoidance- (hich are sometimes prominent and sometimes subtle. Behavioral costs ta*e the form of behaviors that temporaril, reduce distress :li*e cleanin.- hair pullin.- dietin.- or smo*in.; and avoidance of behaviors for fear of emotional distress. Avoidance can be obvious- as (hen Fac*- a 9ietnam veteran (ith posttraumatic stress disorder :PTS&;- isolates himself in his home to avoid the an/iet, he e/periences in cro(ds or (ith other people- or it can be much more subtle- as (hen Leia appears en.a.ed in her (or*- volunteers for numerous or.anizations- and has a broad social net(or* but avoids slo(in. do(n to notice (hat is reall, important to her- leavin. her (ith a .eneral sense of dissatisfaction that she is unable to address effectivel,. Similarl,- Ma,a is focused on her school(or* and does not avoid it- despite the an/iet, it elicits- but she avoids contact (ith people in her life and is una(are of the effect this is havin. on her. She ma, also have lost contact (ith (h, school(or* is important to her and ma, continue her academic pursuits because it is (hat she 0should1 be doin.. The behavioral cost of e/periential avoidance is a particularl, important focus of treatment because it emphasizes the (a, that difficulties interfere (ith individuals4 lives. $ronicall,- behavioral efforts to control- eliminate- or avoid ne.ative internal e/periences often perpetuate distress. A man (ho (ants an intimate relationship but fears reAection ma, not en.a.e in actions that (ould put him in situations (here he mi.ht be reAected b, a potential partner. 2hile this serves the immediate function of reducin. his ris* of bein. reAected- it also increases the chance that he (ill not find a partner. e has effectivel, protected himself from the immediate ris* of reAectionbut he has increased his lon.-term ris* of loneliness and .eneral dissatisfaction. Often- these restrictions in behavior happen automaticall, so
+onceptualization of +linical C Problems E that- althou.h clients feel the pain associated (ith their restricted lives-
the, are not a(are of the role the, pla, in perpetuatin. it. Sometimes avoidance is evident in the 3ualit, of actions rather than their occurrence. %or instance- in our (or* (ith clients (ith .eneralized an/iet, disorder- (e have often found that the, seem to be en.a.in. in the areas of life that matter to them :e...-
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Aobs the, value- spendin. time (ith their children;. 2hen clients be.in to monitor their activities carefull,- ho(ever- it becomes clear that the, are not full, present (hen the, are en.a.in. in these actions. $nstead- the, are (orr,in. about (hat ma, happen ne/t- in another domain. Similarl,- clients ma, distract themselves or hold bac* emotionall, in certain conte/ts as a (a, of avoidin. distress from potential reAection or hurt. %or instance- &e/a client (ho feared abandonment- (ent throu.h the motions of developin. a ne( relationship but *ept himself distant emotionall, (hen he (as (ith his partner as a (a, of avoidin. this feared outcome. This distancin. could have provo*ed separation- (hich he (ould have e/perienced as abandonment- confirmin. his fear and reinforcin. the behavior. All of these forms of disen.a.ement can limit clients4 satisfaction and success in various areas- further drivin. e/periential avoidance and perpetuatin. distress. Another (a, in (hich clients mi.ht unintentionall, diminish their satisfaction is b, appl,in. the same Aud.mental- ri.id (a, of respondin. to e/ternal situations as the, do to their internal e/perience. Acceptance- and mindfulness-based approaches hi.hli.ht the role that Aud.ment of e/ternal events can pla, in sufferin.. Repeatedl, (ishin. that thin.s (ere other than the, are :e...- one4s partner (as different- one4s collea.ues (ere different; can prolon. distress and interfere (ith effective action. Linehan :6==Eb; .ives the e/ample of choosin. to become stuc* in an an.r, and frustrated state (hen drivin. behind someone (ho is .oin. too slo(l, in the fast lane of the hi.h(a,. She su..ests that an alternative (ould be to notice that the person is drivin. more slo(l, than ,ou (ould prefer and s(itch to another lane- (ithout .ettin. cau.ht up in ho( that person should be drivin. differentl,. This *ind of ri.id attachment to the (a, thin.s or people should be is often a factor in the difficulties people have. Brin.in. a(areness to this (a, of relatin. to our (orld can help us ma*e more effective choices. a,es- Strosahl- and 2ilson :6===; hi.hli.ht the (a,s that habitual patterns of e/periential avoidance ma, lead individuals not to attend to the (a, the, (ant to be livin. their lives. $nstead- the, ma*e choices based on avoidin. distress. $n essence- individuals choose avoidance-based rather than approach-based paths- interferin. (ith their abilit, to approach the lives the, (ant to be livin.. Often- these 0choices1 happen outside of a(areness. $ndividuals overlearn patterns of en.a.in. in or avoidin. behaviors and are not a(are that other- less behaviorall, restrictive options are available. An important first step of treatment is brin.in. a(areness to behaviors so that intentional choices rather than reactive behaviors can be.in to influence individuals4 actions.
GOALS AND .ET,ODS OF INTER%ENTION

&ra(in. from the model presented above- ABBTs aim to :6; alter individuals4 relationships (ith their internal e/periences- :>; reduce ri.id e/periential avoidance and increase fle/ibilit, and choice- and :E; increase action in valued directions. The methods used to achieve each of these .oals are described in detail throu.hout the boo*. Belo(- (e provide a brief overvie(. $ltering relationships with internal experiences includes e/pandin. and
+onceptualization of +linical Problems clarif,in. internal a(areness
@ to counter the restricted or occluded a(areness that individuals often e/perience. $n addition- an emphasis is placed on cultivatin. a nonAud.mental- compassionate relationship (ith e/periences as the, arise to reduce reactivit,- fear- and
C B
Aud.ment- (hich have been found to increase distress- motivate e/periential avoidance- and interfere (ith functionin.. %inall,- this .oal includes cultivatin. an e/perience of thou.htsfeelin.s- and sensations as naturall, occurrin. and transient and reducin. an e/perience of them as indicators of a permanent truth. %or instance- Ma,a- (ho habituall, e/periences ph,siolo.ical sensations of an/iet, and interprets these as evidence of her fra.ilit,- vulnerabilit,- and inabilit, to cope- (ould en.a.e in a ran.e of practices desi.ned to help her notice the sensations as the, arise- feel compassion for herself for e/periencin. them- see them as overlearned ph,sical sensations that elicit a ran.e of reactions but that do not define her- and e/pand her a(areness to notice other e/periences and sensations that co-occur (ith an/iet, as (ell as the (a, that an/iet,-related sensations subside over time. Several t,pes of interventions can be used to assist in meetin. this .oal. Psycho# education :described in depth in +hapter @; helps clients understand the nature of internal e/periences :specificall, the function of emotions; and the role that these t,pes of relationships to internal events can pla, in sustained distress and restrictions in their lives. Sel"#monitoring can help enhance clients4 a(areness of their internal e/periences- especiall, the (a, these e/periences rise and fall and their connection to conte/ts and behaviors. #nderstandin. is not sufficient for chan.in. these overlearned- deepl, in.rained relationships. Therefore- si.nificant time is devoted to a ran.e of experiential practices that assist in cultivatin. ne( (a,s of relatin. to internal e/periences. These mindfulness- and acceptance-based strate.ies are described in depth in +hapter B. +lients en.a.e in both formal :specific- planned practice of a particular techni3ue; and informal :appl,in. s*ills to dail, livin.; mindfulness practice- both (ithin and bet(een sessions. 2hile standard practices ma, be most beneficial to be.in (ith :in order to help clients develop the basic s*ills of attendin.noticin.- and allo(in. intentionall,;- the, can be developed over time to tar.et specific aspects clients find challen.in.. Other acceptance-based- or defusion- strate.ies are dra(n from A+T- such as labelin. thou.hts and feelin.s to brin. a(areness to them as separate- rather than fusede/periences. The second .oal of treatment is reducing e""orts at experiential avoidance while increas# ing choice and "lexibility. This includes brin.in. a(areness to the (a, that a ran.e of behaviors and s,mptoms ma, function as efforts to avoid or escape internal distress. +lients are also encoura.ed to practice and learn ho( to choose- rather than reactin a potentiall, evocative situation- reducin. the role that e/periential avoidance pla,s in determinin. their actions. &evelopin. a ne(- unentan.led relationship (ith internal e/periences (ill naturall, decrease the habitual pull to ri.idl, avoid or escape distressin. e/periences. +ultivatin. a curious- invitin. stance to(ard internal e/perience (ill help reduce e/perientiall, avoidant tendencies. Man, of the methods described above also tar.et this .oal of treatment. Ps,choeducation presents e/amples of ho( tr,in. to control internal e/periences can increase difficulties. 2e encoura.e clients to loo* to their o(n e/perience to see (hether this is true for them. 2e help clients increase fle/ibilit, b, noticin. ho(- althou.h thou.htsfeelin.s- and sensations seem to pull for particular actions- (e can separate them and
+onceptualization of +linical C Problems choose responses rather than reactin.. Monitorin. helps clients see 7 ho(
e/periential avoidance affects their lives and identif, earl, cues to conte/ts in (hich to practice an acceptin.- rather than avoidant- response. Mindfulness- and acceptance-based practices help develop the s*ill of acceptance- increasin. clients4 fle/ibilit, in the (a,s the, respond to conte/ts that elicit intense reactions.
C 8
%inall,- ABBTs emphasize the .oal of increasing valued action. This includes refrain- in. from actions that ma, be ver, temptin. in the moment :often because the, serve an e/perientiall, avoidant function; but are not in line (ith the (a, the client (ants to live his or her life and en.a.in. in actions that matter to the individual but have been avoided. $mportant components of this .oal include identif,in. and clarif,in. (hat matters to the individual- brin.in. a(areness to moments (hen choices could be made based on these values- and en.a.in. in action in desired directions. All the methods that promote the first t(o .oals also serve this .oal- in that en.a.- in. in chosen action is facilitated b, an unentan.led- defused relationship to one4s e/perience and an abilit, to choose a none/perientiall, avoidant response. $n addition- ps,- choeducation and monitorin. help brin. a client4s attention to (hat is important to him or herto set the sta.e for chosen action. 2ritin. e/ercises serve to clarif, valuesas does mindfulness practice. 'onreactive- decentered a(areness can allo( one to re"lectively see (hat matters- rather than re"lexively endorsin. values based on societal pressure or fears :Shapiro- +arlson- Astin- < %reedman- >??B;. %inall,- bet(een-session behavioral e/ercises- in (hich actions are chosen and planned for- en.a.ed in- and revie(ed- allo( clients to e/pand their behavioral repertoire and en.a.e more full, in their lives. These behavioral chan.es often elicit ne( t,pes of problematic relationships (ith internal e/periences and impulses that promote e/periential avoidance- feedin. bac* into the previous t(o .oals.
CONCLUSION
ABBTs dra( from this conceptualization of clinical problems b, developin. an individualized case formulation that hi.hli.hts the (a, a client4s presentin. problems can be e/plained b, the model. "oals for treatment tar.et each of these three elements :and their interrelationships;- and intervention strate.ies are chosen to meet these .oals. $n the ne/t chapter(e present assessment methods that can be used to develop an individualized case conceptualization and treatment plan based on this model. 2e also describe in detail the intervention strate.ies that specificall, tar.et problematic relationships (ith internal e/periences- e/periential avoidance- and behavioral constriction :i.e.- failure to en.a.e in valued actions;.
Tw"
+linical Assessment of Relevant &omains
The first step to (or*in. (ith a client from an acceptance-based behavioral perspective is to conduct a comprehensive assessment of the nature and e/tent of the client4s presentin. problems- ps,cholo.ical status- attitudes to(ard internal e/periences :e...- emotions- ph,sical sensations;- common copin. strate.ies :includin. e/periential avoidance;- 3ualit, of life- and previous e/perience in treatment. 'ot onl, is a careful and s,stematic assessment critical to developin. an accurate case conceptualization and an informed treatment plan- but it also helps validate the client4s e/perience and develop a stron. therapeutic alliance. $n this chapter- (e focus primaril, on the assessment strate.ies to be used in the initial sessions- but on.oin. assessment throu.hout therap, :discussed in +hapter =; is essential as it provides important information about the potential efficac, of the intervention- encoura.es a rapid response to unproductive strate.ies- facilitates chan.e b, providin. feedbac*- motivates both the client and therapist- enhances accountabil- it,- and demonstrates the effectiveness of treatment to relevant third parties :2ood,- &et(eilerBedell- Teachman- < O4 earn- >??C;. Belo( is a description of each of the domains that are important to assess (hen (or*in. (ith a client from an acceptance-based behavioral perspective. $n order to ma*e this chapter useful for therapists (or*in. (ith a (ide variet, of clients- (e have been overinclusive in describin. potential tar.ets of assessment. $n our o(n practice- (e select a subset of these measures based on the needs of the individual- usuall, includin. at least one measure from each domain. Althou.h man, of the domains can be assessed throu.h the use of a careful clinical intervie(- (e also underscore the importance of usin. selfmonitorin. bet(een sessions to .ather information about the uni3ue pattern of s,mptoms and problem behaviors e/perienced b, clients. Additionall,- (e ma*e some recommendations about the use of specific intervie(s and 3uestionnaires that ma, provide valuable information throu.h- out the assessment process. $n our selection of instruments- (e have tried to heed the advice of 2ood, and her collea.ues :>??C; in that
(e focus on measures (e find to be hi.hl, applicable :in that the, assess constructs that are important and meanin.ful to the client and that .uide treatment;- acceptable :brief and user-friendl,;- practical :minimal
EC
E @
cost- eas, to score and interpret;- and psychometrically sound :reliablevalid- and sensitive to chan.e;.
S/.$TO.0+ASED ASSESS.ENT +r"a) O(er(iew "f $resentin1 C"ncerns

2e start the assessment process b, tr,in. to .et a sense of the client4s presentin. concerns- desired life directions- and current factors that motivated him or her to see* treatment. T,picall,- this initial report (ill include a description of ps,cholo.ical s,mptoms :e...- difficult, concentratin.- h,perarousal;- current emotional state :e...- sad- an/iousan.r,;- and difficulties in functionin. that are impactin. 3ualit, of life :e...interpersonal conflicts- problems at (or*- diminished ph,sical health and (ell-bein.;. Persons :6=8=; and 2ood, and collea.ues :>??E; su..est thatearl, in the assessment period- clinicians develop a comprehensive problem list- (hich can be used to identif,- priori- tize- and mana.e all of the client4s current difficulties. %or e/ample- &ere* initiall, presented (ith complaints about depression- includin. depressed mood- fati.ue- difficult, sleepin.decreased appetite- and difficult, concentratin.. e also noted that he (as 3uite irritable both at (or* and (ith his partner. is partner (as also distressed about &ere*4s lac* of se/ual interest and (as threatenin. to leave the relationship. &ere* described spendin. most of his free time (atchin. television and pla,in. video .ames. e also admitted to smo*in. mariAuana almost ever, ni.ht and on the (ee*end in order to 0.et throu.h1 his leisure time. &ere* had missed 6? da,s of (or* over the previous E months due to unspecified illnesses :colds- headaches- etc.; and had been .iven a (ritten (arnin. that he could not have an, additional une/cused absences over the ne/t B months. 2e (or*ed (ith &ere* to create a problem list :%i.ure >.6;. 2hen a client presents (ith multiple complaints and concerns- it can be difficult to *no( (here to be.in in treatment. As discussed in +hapter E- the acceptance-based case conceptualization aims
Sad mood Fatigue Difficulty sleeping Decreased appetite Difficulty concentrating Irritability Decreased sexual interest Diffuse somatic complaints Marijuana use Limited recreational activities Limited social contact Relationship difficulties Attendance issues at or! Interpersonal conflict at or!
B PRA+T$+! FIGURE 2343 &ere*4s problem list.
M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $'
E 7
to propose an underl,in. mechanism that accounts for the problems enumerated on the problem list and tie them to.ether in a (a, that (ill .uide treatment. 2e also ma*e an effort to learn about the client4s cultural identit,. A culturall, sensitive approach to assessment is aimed at ensurin. that the client4s problems are accuratel, understood and defined- ta*in. into account cultural norms and e/pectations- informin. the development of an appropriate treatment plan that ade3uatel, meets the needs of the clientand demonstratin. respect for the client4s culture in an attempt to promote a stron. therapeutic alliance :Tana*a-Matsumi- Seiden- < Lam6==B;. The therapeutic relationship is a critical component of ABBT that is assumed to foster an environment in (hich the client can be.in to develop a self-acceptin. and self- compassionate stance. ABBTs re3uire a si.nificant commitment on the part of the client as e/tensive bet(een-session practice (ith mindfulness and valued actions is encour- a.ed. $n our e/perience- a stron. therapeutic relationship increases en.a.ement in and compliance (ith therapeutic activities. As discussed in more depth in +hapter 66- understandin. a client4s cultural identit, can inform man, facets of ABBT. +ultural factors can pla, a si.nificant role in ho( one vie(s one4s emotions- ho( emotions are vie(ed b, one4s famil, members- and the t,pes of values :e...individualistic or interdependent; that are personall, held. Atten- tion to ho( e/ternal forces such as economic disadvanta.e and oppression affect a client informs the conceptualization of the client4s presentin. issues and the choice of therapeutic strate.ies. $n3uirin. about culturall, specific sources of support can help communicate respect and identif, naturall, occurrin. supports that can be dra(n on in later behavioral interventions : a,s>??8;. a,s describes a multidimensional approach to assessin. culture that includes attention to the client4s :6; a.e and .enerational influ- ences:>; developmental and ac3uired disabilities- :E; reli.ion and spiritual orientation- :C; ethnicit,- :@; socioeconomic status- :B; se/ual orientation:7; indi.enous herita.e- :8; national ori.in- and :=; .ender. Once (e have a sense for our clients4 cultural identit, and presentin. problems- (e as* them specificall, to describe the (a,s the, (ould be livin. life differentl, if the presentin. problems (ere not servin. as obstacles. Often- clients present to therap, in such distress and despair that the, can onl, focus on the fre3uenc, and intensit, of their painful e/periences. o(ever- behavioral chan.e aimed at increasin. valued life activities is an essential component of ABBTs. Therefore- both informal and formal methods of assessin. valued directions are indicated. %inall,- as a (a, of assessin. readiness for chan.e- (e encoura.e clients to tal* about the internal and e/ternal factors that motivated help see*in.. Obviousl,- clients (ho come to therap, independentl, are t,picall, more motivated than those encour- a.ed :or re3uired; to see* treatment b, others. o(ever- (e often share (ith our clients our vie( of motivation. 2hile some assume motivation to be a trait or personalit, feature- (e conceptualize motivation from a behavioral perspective. Simpl, put- (e believe clients are motivated to chan.e (hen the positive re(ards of chan.e seem more reinforcin. than the ne.ative conse3uences of en.a.in. in chan.e efforts. %or instance- Maria (as a client dia.nosed (ith borderline personalit, disorder (ho described herself as a laz, procrastinator (ith no
E M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' 8 PRA+T$+! motivation to pursue a career. %urther discussion uncovered that the shame
and self-dis.ust she felt about her limited emplo,ment histor, prevented her from even considerin. the t,pe of career she could potentiall, (ant.
E =
%rom this perspective- (e (elcome and e/pect clients (ho feel both disconnected from the re(ards associated (ith ma*in. a life chan.e and painfull, a(are of the obstacles to ma*in. this chan.e to present (ith ambivalence. The .oal of ABBT is to increase the salience of positive re(ards of chan.e b, helpin. clients access (hat is personall, meanin.ful about their .oals for treatment and decrease the size and ma.nitude of obstacles b, chan.in. the relationship clients have (ith their internal e/periences. Once (e have a broad overvie( of these presentin. issues- (e delve deeper into the assessment process b, more s,stematicall, assessin. a variet, of domains.
$s!ch"&ath"l "1!
a,es and his collea.ues :6==B; criticized the (idel, held medical s,ndromal model of ps,chopatholo.,- citin. the hi.h rates of comorbidit,lo( treatment utilit,- and fre- 3uent irrelevance of the dia.nostic model to the t,pes of presentin. problems t,picall, seen in clinical practice. As an alternative- he and his collea.ues proposed a dimen- sional- functional approach to ps,chopatholo., that assumes that man, forms of ps,chopatholo., are best conceptualized as e/periential avoidance. 2hile (e support this perspective- for a number of practical and clinicall, relevant reasons :e...- insurance re3uirements- ease of communication bet(een providers- validation of clients4 e/periences- appropriateness of treatment recommendations .iven current standards of practice;- (e continue to assess our clients to determine (hether or not the, meet criteria for specific A/is $ disorders- accordin. to the %iagnostic and Statistical &anual o" &ental %isorders- %ourth !dition :&SM-$9;. Often- (e find that a structured or semistructured intervie( helps us learn more about the specific s,mptoms and stru..les that our clients e/perience. $n several cases- a s,stematic assessment has revealed the presence of important life events andDor s,mptoms that a client ma, not other(ise readil, share. %or instance- .iven the hi.h comorbidit, bet(een maAor depressive disorder :M&&; and posttraumatic stress disorder :PTS&;it is common for clients to present (ith s,mptoms of M&& (ho ma, also have si.nificant trauma histories and related s,mptoms that can .o undetected. Similarl,- clients ma, be embarrassed to disclose their dependence on ille.al substances or their thou.hts about suicide unless the, are directl, as*ed about such problems in a compassionate and professional manner. %or man, of the clients (e see- the An/iet, &isorders $ntervie( Schedule for &SM- $9 :A&$S-$95 &i'ardo- Bro(n- < Barlo(- 6==C;- can be a useful .uide for comprehen- sivel, evaluatin. &SM-$9 an/iet, and mood disorders. The Structured +linical $ntervie( for &SM-$9 A/is $ &isorders+linician 9ersion :S+$&-+95 %irst- Spitzer- "ibbon< 2illiams- 6==B; is also an efficient- clinical tool that assesses those &SM$9 dia.noses most commonl, seen b, clinicians :mood- ps,choticsubstance use- an/iet,- eatin.- and somatoform disorders; and includes the dia.nostic criteria for these disorders (ith cor- respondin. intervie( 3uestions.
C M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' ? There are PRA+T$+! also a number of .lobal and s,mptom-specific 3uestionnaires
that can be used to provide more information about the nature and severit, of ps,cholo.ical s,mptoms e/perienced b, the client. The &epression An/iet, Stress ScalesG>6-$tem 9ersion :&ASS->65 Lovibond < Lovibond6==@; is a >6-item measure that ,ields separate scores of depressionan/iet, :i.e.- an/ious arousal;- and stress :e...- tension;. The Brief S,mp-
C 6
tom $nventor, :BS$5 &ero.atis < Spencer- 6=8>; can also be a useful 3uestionnaire measure for assessin. overall ps,cholo.ical distress. The BS$ provides information about a client4s s,mptom report on nine primar, s,mptom dimensions and ,ields three more .lobal indices of ps,cholo.ical functionin..
$"tentiall! +eha(i"rs
,armful
!n.a.ement in self-inAurious and impulsive behaviors- such as deliberate self-harm :e...- cuttin.- burnin.;- substance misuse- unsafe se/ual practices- and compulsive spendin.- .amblin.- and eatin.- can be a form of e/periential avoidance that is important to assess. %or man, clientsthese behaviors are also associated (ith si.nificant shame- (hich means the, are fre3uentl, underreported. $t can be clinicall, useful to routinel, as* clients (hether or not the, use alcohol- dru.s- food- or potentiall, dan.erous activities as a (a, to cope (ith their emotional pain. &irectl, as*in. about embarrassin. and ris*, behaviors in a matter-of-fact (a, demonstrates acceptance and validation and increases the probabilit, that clients (ill be (illin. to disclose such information. $t can also be useful to overestimate the fre3uenc, of potentiall, harmful behaviors durin. 3uestionin. to .et a more accurate self-report. %or e/ample- durin. a phone screenin.- a client named Rochelle (as as*ed ho( man, drin*s she consumed each da, and ans(ered- 0about one or t(o15 ho(ever- durin. the clinical intervie(- she (as presented (ith an overestimateG0So- do ,ou t,picall, have about si/ to seven drin*s a da,K1Gand she disclosed that she (as avera.in. about four to five drin*s per da,. $n addition to as*in. about fre3uenc, of certain behaviors- it can also be useful to in3uire about their conse3uences. The +A"! :Ma,fieldMcLeod- < all- 6=7C; is a short and simple (a, to screen for problematic alcohol use. The client is as*ed if he or she should cut :+; do(n on drin*in.if others are :A; anno,ed b, his or her drin*in.- if he or she has ever felt :"; .uilt, about drin*in.- and (hether he or she ever has an :!; e,e-openin. drin* in the mornin.. 2hile t(o affirmative responses are t,picall, su..estive of the presence of an alcohol use disorder- even one positive response merits further e/ploration. +lients (ho have a lo( threshold for toleratin. emotional pain ma, also be at hei.htened ris* for suicidal behavior. +hiles and Strosahl :>??@; provide a compellin. discussion of ho( the assessment of suicidal behavior must include both ethicall, and le.all, responsible ris* assessment and a therapeuticall, efficacious means of offerin. the client hope. The, underscore the importance- (hen e/plorin. suicidal ideation and intent (ith a client- of validatin. the client4s emotional pain- allo(in. for an open discussion of suicidal thou.hts- and most notabl, reconceptualizin. suicidal behavior as an attempt to solve problems that are seen as intolerableinescapable- and interminable. %or instance- An.el (as a client (ho (as seen for clinicall, si.nificant s,mptoms of PTS&. "iven his lon. histor, of bein. involuntaril, hospitalized for suicidal ideation- he (as hesitant to share his suicidal thou.hts (ith a therapist- (hich parado/icall, increased the intensit, of thou.hts- his feelin.s of isolation- and ultimatel, the prob-
C M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' > abilit, that PRA+T$+! he (ould be rehospitalized. &urin. an assessment meetin.-
An.el4s ne( therapist shared his vie( that people en.a.e in all sorts of behaviors that the, *no( are harmful because the, find their emotional pain so intense. The therapist normalized suicidal thou.hts b, su..estin. that suicide often seems li*e the onl, option to someone
C E
(ho is in si.nificant distress. e encoura.ed An.el to tal* openl, about his thou.hts and feelin.s and offered An.el the possibilit, that he could learn ne( problem-solvin. s*ills :e...- acceptance and tolerance of emotional pain- behavioral activation; throu.h ABBT as an alternative to suicide. A number of individual and situational factors should be assessed to inform the clinician of the potential tar.ets for treatment to decrease suicidalit,- includin. co.nitive st,le :e...- infle/ibilit,;- problem-solvin. st,le :e...- deficit in s*ills;- emotional pain and sufferin.- emotionall, avoidant copin. st,le- interpersonal deficits- self-control deficits- and environmental stress and support :+hiles < Strosahl- >??@;. The Reasons for Livin. $nventor, :Linehan- "oodstein- 'ielsen- < +hiles- 6=8E; can be used to measure a ran.e of beliefs :social and copin. beliefs- responsibilit, to famil,- child-related concerns- fear of suicide- fear of social disapproval- and moral obAections; that ma, be important in preventin. a client from attemptin. suicide.
RELATIONS,I$ TO INTERNAL E#$ERIENCES Awareness "f Em"ti"nal E'&erience

A critical part of our assessment involves e/plorin. the client4s relationship to his or her internal e/periences :e...- emotions- thou.htsinternal sensations;. %irst- (e pa, attention to the level of a(areness and specificit, (ith (hich clients describe their emotional state. Often- clients present to therap, (ith a nonspecific complaint of .eneral ne.ative affect and stru..le si.nificantl, to conve, a more nuanced description of their current emotional state. $n these cases- it can be useful to as* the client to complete a mood adAective chec*list such as the EB-item Mood AdAective +hec* List :MA+L5 'o(- lis- 6=B@; or the >?-item Positive and 'e.ative Affect Schedule :PA'AS5 2atson- +lar*< Telle.en- 6=88; at different points in the da,. 'ot onl, does this assessment provide valuable information about ran.e of affect- but it also be.ins to .ive clients a more comple/ vocabular, to describe their internal e/perience. Man, clients be.in therap, una(are of the moment-to-moment fluctuations in mood the, are e/periencin.. %or instance- (e once (or*ed (ith a client- Sharon- (ho described a panic attac* that lasted appro/imatel, > (ee*s. &espite the fact that the human bod, is ph,sicall, incapable of sustainin. such a hi.h level of arousal for that lon.- Sharon4s e/perience (as that her fear and arousal (as constant. $n this case- a ver, simple monitorin. sheet can be used as a (a, of teachin. a patient li*e Sharon to notice the variations in her mood. A ratin. scale ran.in. from ? to 6?? can be .iven to the client so that he or she can indicate the intensit, of an e/perienced emotion several times a da,Gin the mornin.- afternoonevenin.- and before bed :see %orm >.6- p. @6;. $n order to improve the validit, of such an assessment- it is important to spend some time creatin. personalized behavioral anchors for the ratin. scale. The client can be as*ed to thin* of a situation in (hich he or she e/perienced no an/iet, at all :?;- moderate an/i- et, :@?;- and severe an/iet, :6??;. 2hen completin. the dail, assessment measure- the client can consider his or her current emotional state relative to the emotions evo*ed in those anchor situations
C ma*in. a PRA+T$+! (hen numerical ratin.. Similarl,- clients are often una(are of specific situational tri..ers that elicit particular emotions. Once a.ain- individualized self-monitorin. sheets can be developed
C @
to better assess these domains :see %orm >.>- p. @>;. %or e/ample- a client can be as*ed to notice the emer.ence of t(o or three stron. emotions each da,. 2hen the client e/periences one of those emotions- he or she can be as*ed to note the da, and time- the situation- the emotion elicited- and an, accompan,in. thou.hts or ph,sical sensations. 2hile an intervie( and self-monitorin. ma, reveal difficulties in identif,in. and describin. emotions- there are also 3uestionnaires that assess this response st,le. %or instance- the T(ent,-$tem Toronto Ale/ith,mia Scale :TAS->?5 Ba.b,- Par*er- < Ta,lor6==C; is a 3uestionnaire that measures the construct of ale/ith,mia. Ale/ith,mia is characterized b, difficulties identif,in. and describin. emotions- a tendenc, to minimize emotional e/perience- and a pattern of focusin. attention e/ternall,. $tems such as 0$ am often confused about (hat emotion $ am feelin.1 and 0$ often don4t *no( (h, $ am an.r,1 are rated on a @-point scale ran.in. from 6 :0stron.l, disa.ree1; to @ :0stron.l, a.ree1;. The TAS->? ,ields an overall score and scores for three subscalesL &ifficult, &escribin. %eelin.s- &ifficult, $dentif,in. %eelin.s- and !/ternall, Oriented Thin*in.. The &ifficulties in !motion Re.ulation Scale :&!RS5 "ratz < Roemer>??C; is a EB-item measure that can provide comprehensive information about various aspects of a client4s emotion re.ulation :discussed in more depth belo(;. T(o specific subscales of this measure directl, measure a(areness of emotions :e...- 0$ pa, attention to ho( $ feel1; and clarit, of emotions :e...- 0$ am confused about ho( $ feel1;.
.in)fulne ss
ABBTs aim to increase mindfulness- thus assessment of this construct is essential. A(areness of emotions is a *e, feature of mindfulness5 thereforesome of the measures discussed in these sections can be used to measure both constructs- but there are other components to mindfulness be,ond a(areness. Baer- Smith- op*ins- Hrieteme,er- and Tone, :>??B; reveal mindfulness to be a multifaceted construct consistin. of five dis- tinct elementsL observation of and attention to one4s internal e/periencedescription and labelin. of one4s e/perience- the abilit, to en.a.e in activities (ith a(areness and (ithout distraction- the allo(in. and nonAud.in. of e/perience- and nonreactivit, to inner e/perience. 2hile man, of these facets of mindfulness can be assessed throu.h clinical intervie( and some of the self-monitorin. e/ercises noted above- there are also a .ro(in. number of 3uestionnaires that can be 3uite useful in assessin. the different elements of mindfulness. The Mindful Attention A(areness Scale :MAAS5 Bro(n < R,an- >??E; is a 6@-item scale that measures a sin.le factor of mindfulnessL the .eneral tendenc, to be attentive to and a(are of present-moment e/periences in dail, life. $tems such as 0$t seems $ am Mrunnin. on automatic4 (ithout much a(areness of (hat $4m doin.1 are
C M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' B rated on a PRA+T$+!
B-point scale ran.in. from 0almost al(a,s1 to 0almost never.1 2hile this measure is helpful in assessin. a(areness- it does not tap into man, of the other important elements of mindfulness. Several other measures of mindfulness are desi.ned to capture more of its facets. %or instance- the %reibur. Mindfulness $nventor, :%M$5 Bucheld- "rossman< 2alach>??6; is a E?-item 3uestionnaire that assesses nonAud.mental presentmoment observation and openness to ne.ative e/periences. The Hentuc*, $nventor, of Mindfulness S*ills :H$MS5 Baer- Smith- < Allen- >??C; is a recentl, developed E=-item scale desi.ned
C 7
to measure four of the five aspects of mindfulness described aboveL observation- description- actin. (ith a(areness- and acceptin. (ithout Aud.ment. There is also pre- liminar, support for the development of a E=item measure- the %ive %acet Mindfulness Nuestionnaire :%%MN5 Baer et al.>??B;- (hich includes items from all of the measures described above.
Fusi"n with E'&eriences
Internal
The model drivin. ABBT proposes that bein. fused (ith or hoo*ed b, ,our internal e/periences drives attempts at e/periential avoidance. Thus- one of the .oals of therap, is to help clients decenter or defuse from their thou.hts- emotions- ima.es- and ph,sical sensations. One potentiall, useful (a, to assess an individual4s fusion (ith his or her o(n thou.hts and feelin.s is to as* him or her to rate the believabilit, of different thou.hts and internal e/periences that arise. 2hile there are no .eneral measures to assess this construct- researchers have developed contentspecific measures that as* individuals to rate the believabilit, of the content of depressive thou.hts :Iettle < a,es- 6=87;- hallucinations and delusions :Bach < a,es- >??>;- and sti.matizin. attitudes : a,es- Bissett- et al.>??C;. The Thou.htJAction %usion Scale :TA%S5 Shafran- Thordarson- < Rachman- 6==B; is a 6=-item scale that has been used primaril, (ith obsessiveJcompulsive disorder :O+&; but it ma, be useful more .enerall, as a measure of co.nitive fusion. The TA%S taps into t(o componentsL :6; the belief that thin*in. about an unacceptable or disturbin. event (ill increase the probabilit, that it ma, occur- and :>; the belief that havin. an unacceptable thou.ht is almost the moral e3uivalent of carr,in. out an unacceptable action. $tems such as 0Thin*in. of cheatin. in a personal relationship is almost as immoral to me as cheatin.1 and 0$f $ thin* of a relativeDfriend bein. in a car accident- this increases the ris* heDshe (ill have a car accident1 are rated on a @-point scale ran.in. from ? :disa.ree stron.l,; to C :a.ree stron.l,;.
Distress Relate) E'&eriences
t"
Internal
There are also a number of 3uestionnaires that have been specificall, developed to assess ho( distressed a client is b, his or her internalparticularl, emotional- e/perience. An/iet, sensitivit,- or 0fear of fear-1 is a construct common in panic and other an/iet, disorders. The An/iet, Sensitivit, $nde/ :AS$5 Reiss et al.- 6=8B; is a 6B-item 3uestionnaire that measures reactivit, to an/iet,-related s,mptoms. $tems such as 0$t scares me (hen m, heart beats rapidl,1 are rated on a @-point scale ran.in. from ? :0ver, little1; to C :0ver, much1;. The Affective +ontrol Scale :A+S5 2illiams- +hambless- < Ahrens- 6==7; is a C>-item 3uestionnaire that e/tends the 0fear of fear1 construct to include distress about an/iet,depressionan.er- and positive affective states. Sample items include 0$t scares me (hen $ am nervous1 :an/iet, subscale;- 0&epression is scar, to meG$ am afraid that $ could .et depressed and never recover1 :depression subscale;- 0$ am afraid that lettin. m,self feel reall, an.r, about somethin.
8 lead mePRA+T$+! could into an unendin. ra.e1 :an.er subscale;- and 0$ (orr, about losin. self-control (hen $ am on cloud nine1 :positive affect subscale;. Responses are scored on a 7-point scale ran.in. from 6 :0ver, stron.l, disa.ree1; to 7 :0ver, stron.l, a.ree1;.
C =
CURRENT AND $AST CO$ING STRATEGIES General C"&in1 Strate1ies

A core assumption of ABBT is that internal and e/ternal attempts to control or escape uncomfortable thou.htsfeelin.s- ima.es- and sensations create si.nificant ps,cholo.i- cal distress and interfere (ith life satisfaction. Therefore- a careful assessment of the copin. strate.ies that a client uses (hen e/periencin. ps,cholo.ical distress is critical to the development of an effective pro.ram of treatment. 2e start this assessment process b, as*in. the client to describe the (a,s that he or she has tried to cope (ith the presentin. problems :t,picall, painful thou.hts and feelin.s;. 2e specificall, as* about the use of internal control strate.ies such as ima.er,distraction- self-tal*- (ishful thin*in.- and e/periential avoidance. o(everrather than simpl, assessin. the .eneral use and utilit, of these strate.ies(e as* the client to offer specific e/amples of times (hen he or she used an internal control strate., and the short- and lon.-term outcomes. Selfmonitorin. is also a useful method for assessin. the fre3uenc, and effectiveness of particular strate.ies :see %orm >.E- p. @E;. %or e/ample- one client (e (or*ed (ith- Bob- reported that distraction (as a ver, effective copin. strate., that he (as able to use (hen feelin. e/tremel, an/ious. A more comprehensive evaluation revealed that this strate., (as often ineffective and associated (ith lon.-term ne.ative conse3uences. Bob described usin. distraction as a (a, of mana.in. his an/iet, durin. an interaction (ith his supervisor at (or*. Althou.h he initiall, Aud.ed the strate., to be helpful- a more detailed anal,sis of the situation revealed that- (hile his an/iet, (as decreased in the moment- his sleep (as disturbed for the ne/t three ni.hts as he ruminated on the interaction. %urthermore- it became clear that Bob did not encode or retain the information his supervisor had tried to provide him durin. the interaction. Therefore- Bob had to as* his supervisor to repeat the information in a subse3uent encounter- (hich left him feelin. embarrassed and stressed. Similarl,- Mar, reported that positive self-tal* (as an effective strate., for dealin. (ith her d,sphoric mood. She described several situations in (hich she had successfull, 0tal*ed herself out of1 her depression. Mar, (as as*ed to monitor her mood over the course of the (ee* and to use the self-tal* strate., (henever she felt sad. $n the subse3uent session- she described several instances in (hich she tried to use the strat- e.,- but her mood did not improve. 2ith further assessment- Mar, came to notice that there did not seem to be a consistent relationship bet(een the use of positive self-tal* and improved mood.
S&ecific .easures "f E'&eriential A("i)ance

Because e/periential avoidance is so important to conceptualization and treatment from an acceptance-based behavioral perspective- (e also t,picall, administer at least one 3uestionnaire specificall, aimed at assessin. this form of copin.. The Acceptance and Action Nuestionnaire :AAN5 a,es- Strosahl- et al.- >??C; is the most (idel, used self- report measure of e/periential avoidance- tappin. into both the un(illin.ness to
@ ? remain
in PRA+T$+! contact (ith particular feelin.s and thou.hts and the un(illin.ness to act intentionall, (hile e/periencin. distressin. private events. $tems such as 0$4m not afraid of m, feelin.s1 are rated on a 7-point scale from 6 :0never true1; to 7 :0al(a,s true1;. Several versions of this measure are available. The most common is the nine-item scale- (hich
@ 6
has demonstrated ade3uate ps,chometric properties : a,es- Strosahl- et al.- >??C;. There are also t(o 6B-item versions of the scale that have sho(n some promise in measurin. underl,in. processes that ma, chan.e as a function of treatment. Because each of these three versions has ps,chometric stren.ths and (ea*nesses- man, clinicians opt to use a >>-item version that combines all of the items from the three versions into one measure. %inall,- a 6?-item version of the AAN :the AAN-$$; that aims to address some of the problems of earlier versions :e...- comple/l, (orded items- lo( internal consistenc,; is currentl, under development :%.". Bondpersonal communication;. The Thou.ht +ontrol Nuestionnaire :T+N5 2ells < &avies- 6==C; is a E?item instrument aimed at assessin. the effectiveness of strate.ies used to control unpleasant and un(anted thou.hts. $tems such as 0$ punish m,self for thin*in. the thou.ht1 and 0$ tell m,self not to be so stupid1 are rated on a C-point scale ran.in. from 6 :0never1; to C :0almost al(a,s1;. Althou.h the T+N measures five factors that correspond to different strate.ies for controllin. un(anted thou.hts :distraction- social control- (orr,- punishment- and reappraisal;- punishment and (orr, most clearl, relate to the construct of e/periential avoidance. The 2hite Bear Suppression $nventor, :2BS$5 2e.ner < Iana- *os- 6==C; is another measure aimed at assessin. strate.ies to control thou.hts. Specifi- call,- this 6@-item self-report measure assesses the tendenc, to avoid and suppress one4s un(anted thou.hts. $tems such as 0$ al(a,s tr, to put problems out of mind1 are rated on a @-point scale ran.in. from 6 :0stron.l, disa.ree1; to @ :0stron.l, a.ree1;.
Em"ti"n Re1ulati"n
Emotion regulation is a broad concept that has been used to describe one4s abilit, to modulate :e...- "ross- 6==8;- monitor- and evaluate one4s emotional state :e...- Thompson6==C;. Althou.h this construct is li*el, hi.hl, related to both .eneral copin. strate.ies and mindfulness- it can also be useful to specificall, assess it. "ross and Fohn :>??E; developed the 6?-item !motion Re.ulation Nuestionnaire :!RN; desi.ned to assess individual differences in the habitual use of t(o emotion re.u- lation strate.iesL co.nitive appraisal :e...0$ control m, emotions b, chan.in. the (a, $ thin* about the situation $4m in1; and suppression of emotional e/pression :0$ control m, emotions b, not e/pressin. them1;. !ach item is rated on a 7-point scale ran.in. from 6 :0stron.l, disa.ree1; to 7 :0stron.l, a.ree1;. Hashdan and Ste.er :>??B; modi- fied this measure to develop the ei.ht-item State !motion Re.ulation Nuestionnaire to assess strate.ic attempts to modif, mood durin. the da,. This adapted measure ma, be useful in providin. clients and therapists (ith some individualized information about the relationship bet(een the emotion re.ulation strate.ies used b, a client in different situations and his or her subse3uent emotional response. As described earlier- the &ifficulties in !motion Re.ulation Scale :&!RS5 "ratz < Roemer- >??C; is a comprehensive measure of emotion re.ulation. The scale provides a total score as (ell as si/ subscale scores measurin. difficulties in aspects of emotion re.ulation- includin. acceptance of
> PRA+T$+! emotions :e...02hen $4m upset- $ become embarrassed for feelin. that (a,1;- abilit, to en.a.e in .oal-directed behavior (hen distressed :e...02hen $4m upset- $ have difficult, .ettin. thin.s done1;- impulse control :e...- 02hen $4m upset- $ lose control over m, behaviors1;- and access to strate.ies for re.ulation :e...- 02hen $4m upset- $ believe that there is nothin. $ can do to ma*e m,self feel better1; in addition to the a(areness of emotions and clarit, of emotions subscales
@ E
described earlier. Participants indicate ho( often each item applies to themselves on a @-point Li*ert-t,pe scale- (ith 6 as 0almost never1 :?J6?O; and @ as 0almost al(a,s1 :=6J6??O;. Scores are coded such that hi.her scores indicate .reater difficulties in emotion re.ulation.
Assessin1 Stren1ths
2hile these assessments of problematic (a,s of respondin. to internal e/periences are an important part of a comprehensive assessment- (e also ma*e an effort to assess (a,s that clients are able to cope effectivel, and the stren.ths that the, dra( on. As described in the previous chapterclients often come to treatment (ith narro(ed- critical vie(s of themselves resultin. from fusion (ith their distressin. internal e/periences. As*in. specificall, about stren.ths can help broaden their perspective so that the, also attend to parts of their lives that are re(ardin.. This information helps the therapist plan earl, behavioral assi.nments that are most li*el, to be successful and reinforcin.- supportin. future chan.e efforts.
UALIT/ OF LIFE D"mains "f Functi"nin1

As discussed in +hapter 6- the e/plicit .oal of ABBT is to improve clients4 3ualit, of life fundamentall, and si.nificantl,. 2hile this .oal is implicit in an, form of therap,- ABBT uses a number of clinical methods to help clients en.a.e in behaviors that are consistent (ith personall, relevant values. Therefore- a careful assessment of clients4 behavior and satisfaction in multiple life domains is hi.hl, recommended. 2e commonl, as* our clients to describe their current schoolDoccupational functionin.- notin. an, issues (ith attendance- performance- or dissatisfaction. 2e assess the size and 3ual- it, of clients4 social support net(or*s- particularl, attendin. to si.ns of isolation- lac* of intimac, in relationships- or conflictual relationships. Additionall,- (e as* ho( our clients spend their free time and specificall, assess for the presence of hobbies- leisure activities- and spiritual and communit, interests. Ph,sical health and (ell-bein. are also important tar.ets of assessment. 2hile (e routinel, assess for the presence of si.nificant medical conditions- there are a number of other important health indicators that are related to life satisfaction. %or e/ample- accordin. to the $nstitute of Medicine- @? to 7? million Americans chronicall, suffer from a sleep disorder. A recent poll b, the 'ational Sleep %oundation :>??7; revealed that t(o-thirds of (omen e/perience sleep problems at least a fe( ni.hts a (ee*. Amon. those reportin. poor sleep- 8?O report feelin. stressed out and an/ious- and @@O report feelin. unhappiness- sadness- or depression
@ M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' C PRA+T$+! (ithin the past month. Additionall,- poor sleep is associated (ith less time
spent (ith friends and famil, and decreased se/ual activit,. The relationship bet(een sleep and mental health is comple/ and reciprocal. Ps,- cholo.ical disorders such as M&& and PTS& are characterized b, sleep disturbances5 lac* of sleep contributes to poor moodattention- and concentration5 and prescribed :ps,chotropic medications; and nonprescribed :dru.s and alcohol; substances impact sleep fre3uenc, and 3ualit,. %urthermore- deficits in sleep can intensif, the presence of
ne.ative emotions and reduce the positive effects of .oal-enhancin. activities :Iohar- Tzischins*,- !pstein- < Lavie- >??@;. There are several methods one can use to assess sleep 3ualit,. The Pittsbur.h Sleep Nualit, $nde/ :PSN$5 Bu,sse- Re,nolds- Mon*- Berman- < Hupfer- 6=8=; is a 6=-item self-report measure of sleep 3ualit, and disturbances. Another brief self-report measure is the 6=-item Sleep Scale from the Medical Outcomes Stud, : a,s < Ste(art- 6==>;. $n addition to these 3uestionnaire measures- a sleep diar,- in (hich participants selfmonitor their dail, sleepD(a*e patterns- has been sho(n to be a reliable assessment instrument :Ro.ers- +aruso- < Aldrich- 6==E;. &iet and e/ercise are also important components of 3ualit, of life (orth assessin.. !ven (hen eatin. concerns are not a presentin. problem- poor nutrition and erratic eatin. patterns can threaten a client4s health and (ellbein.. Se/ual functionin. is often overloo*ed as a component of 3ualit, of life. A lar.e epidemiolo.ical surve, conducted in the #nited States :Laumann- Pai*- < Rosen- 6===; found that CEO of female and E6O of male respondents e/perienced some form of se/ual d,sfunction. Problems in se/ual functionin. can ne.ativel, impact mood and strain intimate relationships. Althou.h man, clients are uncomfortable discussin. their se/ualit,- (e have found that it can be 3uite normalizin. to as* about satisfaction in this important life domain as part of a comprehensive assessment of 3ualit, of life. %urthermore- a 3uestionnaire- such as the &ero.atis Se/ual %unctionin. $nventor, :&S%$5 &ero.atis < Melisaratos6=7=;- can be administered to .et an overall sense of a client4s functionin. in this area. The Nualit, of Life $nventor, :NOL$5 %risch- +orn(ell- 9illanueva- < Retzlaff- 6==>; is an e/cellent tool to help the therapist .et an overall sense of a client4s satisfaction across several important domains. Respondents rate the importance of :on a E-point scale; and current satisfaction (ith :on a B-point scale; 6B areas of life :health- self-esteem- .oals and valuesmone,- (or*- pla,- learnin.- creativit,- helpin.- love- friends- children- relatives- home- nei.hborhood- and communit,;. An overall 3ualit, of life score is obtained in addition to a (ei.hted satisfaction profile for the 6B areas assessed.
%alue s
2ilson and "room :>??>5 as cited in 2ilson < Murrell- >??C; developed the 9alued Livin. Nuestionnaire :9LN;- (hich re3uires clients to assess the importance of 6? commonl, valued domains of livin. on a scale of 6J6?L famil,- marria.eDcouplesDintimate relations- parentin.- friendship- (or*education- recreation- spiritualit,- citizenship- and ph,sical self-care. 'e/tclients are as*ed to estimate- usin. a scale of 6J6?- ho( consistently the, have behaved in accord (ith each of the values durin. the past (ee*. The 9LN is primaril, used as a clinical tool to identif, areas of livin. that mi.ht end up bein. tar.ets for treatment. 2ilson and Murrell :>??C; describe three clinicall, notable profiles that can be e/tremel, informative to the therapist. The first common profile reflects a hi.h discrep- anc, bet(een ratin.s of importance and ratin.s of consistenc, in one or more valued domains. %or e/ample- a client (ho is
currentl, out of (or* on disabilit, due to s,mptoms of M&& and (ho hi.hl, values bein. challen.ed and contributin. in the (or*- place mi.ht rate this domain as hi.hl, valued and inconsistentl, pursued. +lients (ith this profile are li*el, to report si.nificant ps,cholo.ical distress and to appear immobilized (ith re.ard to movin. for(ard and ma*in. chan.es in valued domains.
Another pattern (orth notin. is one of e/tremel, lo( importance scores across most or all valued domains. %or instance- a client (ho is e/tremel, isolated- (ith a histor, of social reAection- mi.ht uniforml, rate famil,intimate relations- parentin.- and friendship as all unimportant. Sometimes this pattern of 0not carin.1 ma, actuall, reflect a desire to avoid the pain associated (ith ac*no(led.in. a (ish to be connected (ith others :2ilson < Murrell- >??C;. $n these cases- the clinician can .entl, e/plore if 0not carin.1 is preventin. the client from pursuin. these important life domains. A final notable pattern is that of e/tremel, hi.h total importance and consistenc, scores. Particularl, (hen a client reports little ps,cholo.ical distress- such endorse- ment ma, reflect the client4s desire to present himor herself in a sociall, acceptable (a, :2ilson < Murrell- >??C;. $n our o(n practice- (e have seen a number of clients (ho endorse man, values as hi.hl, important and report that the, are consistentl, actin. in accordance (ith these values but describe si.nificant ps,cholo.ical distress. $n these cases- clients are often 0.oin. throu.h the motions1 of livin. a valued life (ithout brin.in. mindfulness to their e/periences. %or e/ample- 2end, (as a professional (ith an e/citin. and challen.in. careera solid marria.e- and three (onderful children. On the surface- she seemed to be stri*in. a balance bet(een succeedin. in her career and spendin. 3ualit, time (ith her famil,5 ho(ever- upon more careful intervie(in.- it became apparent that 2end, (as not brin.in. mindfulness and intention to her behavior in valued domains. 2hen she (as at (or*- althou.h her performance (as stron.- she (as often distracted (ith thou.hts and feelin.s of .uilt and (orr, about her famil,. At home- she (ould spend time pla,in. (ith her children- but her attention (as focused on thou.hts about (or* and deadlines. er pattern of scores on the 9LN- alon. (ith her stated distress- indicated to her clinician the importance of (or*in. (ith 2end, to brin. mindfulness to her valued activities. !mmons :6=8B; developed an assessment s,stem aimed at assessin. personal strivin.s- a concept similar to that of values. e defined personal strivings as unif,in.- or.a- nizin. abstract constructs- such as (antin. affection from others- that .uide and direct ever,da, behavior. #sin. this s,stem- each strivin. is rated on a number of dimensions- includin. value :happiness or unhappiness associated (ith success in the strivin.;- clarit, re.ardin. the strivin.- ambivalence to(ard the strivin.- commitment- level of importance- e/pectanc, for success- and motives for pursuin. these .oals. &ra(in. from this measure- (hich is primaril, used in research on personalit, and (ell-bein.- Blac*led.e- +iarocchi- and Baile, :>??7; developed the Personal 9alues Nuestionnaire for use in a clinical conte/t. The 3uestionnaire is desi.ned to help clients articulate their values- to identif, (hether their values are intrinsicall, or e/trinsicall, motivated- to rate the personal importance of each value- and to .au.e commitment to the value. 9alues are assessed in the nine domains of livin. described in A+T : a,esStrosahl< 2ilson6===;L famil, relationshipsfriendshipsDsocial relationships- cou- plesDromantic relationships(or*DcareereducationDschoolin.Dpersonal .ro(th and developmentrecreationDleisureDsport- spiritualit,Dreli.ion- communit,Dcitizenship- and healthDph,sical (ell-bein.. +lients are as*ed to read a brief description of each values domain :e...- in the friendshipsDsocial relationships domain
the, are as*ed to thin* about (hat it means be a .ood friend and .iven possible descriptions to consider- such as bein. supportive- consideratecarin.- acceptin.- lo,al- or honest; and then as*ed to articulate an, personal values the, ma, have in this domain. 'e/t- clients are presented (ith nine 3uestions about the value- each rated on a @-point scale- that assess motiva-
tion for holdin. the value- the e/tent to (hich behavior is currentl, consistent (ith the value- commitment to the value- importance of the value- and (hether or not it is a potential area for improvement. Lund.ren- &ahl- and a,es :>??8; have developed the 9alues Bull4s !,e- a measure of values attainment and persistence (hen encounterin. barriers- usin. a series of four pictorial representations of dartboards. The first three dartboards are used to assess the e/tent to (hich clients are livin. consistent (ith their values. The client is as*ed to describe three deepl, held- personall, relevant valued directions that he or she (ould li*e to (or* on in therap,. The center of the dartboard :the bull4s e,e; represents livin. full, in accord (ith that value- and the client is as*ed to mar* ho( close to the bull4s e,e he or she is currentl, livin.. A fourth dartboard is used to assess persistence of actin. in accordance (ith values in the face of ps,cholo.ical barriers such as an/iet, or sadness. The client is as*ed to (rite do(n individual barriers that ma*e it difficult to live consistent (ith his or her values- then to indicate persistence of valued action in the face of the described barriers :(ith the bull4s e,e meanin. the client al(a,s persists;. The distance bet(een the center :bull4s e,e; and the ed.e of all four dartboards is C.@ centimeters- and scores- representin. the distance bet(een the mar* and the bull4s e,e- can var, from ? to C.@- (ith lo(er scores e3ualin. .reater attainment or persistence. 9alues attainment is a mean of the first three dartboards5 persistence throu.h barriers is .enerated b, the sin.le measure. 2hile these measures can be helpful in obtainin. a baseline assessment of values- (e have also found a more in-depth assessment of values throu.hout treatment to be useful. 2e use a series of (ritin. assi.nments in treatment to help our clients obtain a clearer and richer sense of their o(n values. These treatment strate.ies are discussed in +hapter 7.
$RE%IOUS TREAT.ENT
Fust as it is important to full, assess the copin. strate.ies that the client uses to cope (ith difficult ps,cholo.ical events- it is also critical to obtain a comprehensive understandin. of the client4s previous e/periences in therap,. 2e routinel, as* our clients to describe their previous therap,- to note (hich methods and strate.ies the, found most effective- and to describe an, components the, found less useful.
C"1niti(e0+eha(i"ral Treatment
$n our o(n practice- (e have (or*ed (ith a number of clients (ho have previousl, completed a trial of co.nitive-behavioral therap,. Althou.h acceptance-based behavioral approaches sprin. from this tradition- and man, of the methods of traditional +BT are hi.hl, consistent (ith acceptance-based approaches :see +hapter 6?;- one should full, e/plore the client4s e/periences (ith +BT :for more information on the similarities and differences bet(een +BT and acceptance-based approaches- see Orsillo < Roemer>??@5 Orsillo- Roemer- Lerner- < Tull- >??C;. Acceptance-based behavioral
approaches dra( from- and are compatible (ith- +BT techni3ues such as self-monitorin.- e/posure therap,- behavioral activation- and s*ills trainin.. Some (a,s of approachin. irrational thou.hts (ith co.nitive restructurin. are consistent (ith the ABBT .oal of chan.in.
the relationship that the client has (ith his or her internal e/periences. %or e/ample- encoura.in. a client to consider his thou.hts as merel, thou.hts and not facts- to attend a part, even (hen he is feelin. an/ious- and to observe (hat reall, happens in that feared situation mi.ht be part of both approaches to treatment. $n contrast- other co.nitive approaches ma, focus more on chan.in. the content of a specific thou.ht in order to decrease an/iet,- (hich is less consistent (ith an ABBT perspective. %or e/ample- a client (ho is an/ious at parties ma, be as*ed to tr, and replace the thou.ht 0$ feel li*e a fool because $ am not as educated as the other people here1 (ith somethin. li*e 0$ am an interestin. and educated person.1 The rationale of +T in this case (ould be to reduce the fre3uenc, and intensit, of uncomfortable thou.hts- (hich (ould be e/pected to decrease an/iet, and facilitate e/posure to feared situations. Althou.h s,mptom reduction is an obvious .oal of ABBT- the emphasis in this approach is on developin. an acceptin. and compassionate stance to(ard oneself and en.a.in. in actions that are consistent (ith personall, relevant values. As co.nitive-behavioral approaches have .ro(n in popularit,- the term has come to describe a much broader class of disparate techni3ues. Therefore- (e find it useful to as* our clients more specificall, about (hich elements of +BT the, received :e...- ps,choeducation- co.nitive restructurin.- behavioral activation- s*ills trainin.- rela/- ation trainin.e/posure therap,;. %urthermore- if the, report that certain techni3ues (ere not at all useful- (e probe for more detail. %or e/ample- Sheila reported that she (as un(illin. to consider applied rela/ation trainin. in therap, because of a previous unsuccessful trial. #pon more detailed 3uestionin.- it became clear that her previous therap, had involved listenin. to a tape of ocean sounds as a form of rela/ation. 2hen (e (ere able to differentiate applied rela/ation from (hat Sheila had previousl, tried- she became more (illin. to consider it. $t can also be useful to hear a client4s thou.hts about (h, a trial of +BT ma, not have been effective. %or instance- (e often see clients (ho have not benefited from previous e/posure therap,. Fohn- a 9ietnam veteran (ith PTS&- (as un(illin. to tr, e/posure therap, because his e/perience (ith this method had failed. Specificall,- Fohn had completed one session of e/posure therap,- durin. (hich he became e/tremel, aroused and a.itated. !/posure therap, is an e/tremel, po(erful treatment for PTS& that can be enhanced (ith acceptance techni3ues :see +hapter 6?;. Therefore- (hile (e su..ested that Fohn consider en.a.in. in e/posure therap, (ith us- (e provided him (ith a rationale to address his concerns. Specificall,- (e e/plained that (e (ould first provide him (ith mindfulness and defusion s*ills to help diminish the distress associated (ith the painful thou.hts- ima.es- and emotions that e/posure is li*el, to elicit. Often- if a client has had a positive e/perience (ith +BT- he or she ma, stru..le a bit (ith some acceptance strate.ies- (hich could seem inconsistent (ith the co.nitive model that thou.hts cause emotions and that co.nitive restructurin. is needed to alter thou.hts so that the, are more 0rational.1 A careful assessment of the specific methods that (ere found to be useful allo(s the therapist to address these apparent inconsistencies. %or instance- Mar* had found the co.nitive restructurin. he received in previous therap, useful in treatin. his social an/iet, disorder
:SA&; and he e/pressed concern that an acceptance-based approach to treatin. his "A& s,mptoms (ith the current therapist (ould be inconsistent (ith the (or* he had completed. 2e (ere able to dra( parallels for him bet(een the self-monitorin. he completed and the development of the mindfulness s*ill of attention. %urthermore- (e discussed the consistencies
bet(een no lon.er acceptin. certain thou.hts as facts and the decenterin. and defusion s*ills of mindfulness. Rather than directl, confrontin. Mar* about (hether chan.in. the content of his thou.hts (as necessar, for treatment- (e as*ed him if he (as (illin. to e/pand his repertoire and tr, some ne( approaches to cope (ith his emotions (hen co.nitive restructurin. (as ineffective.
N"n)irecti(e Treatment
2hile the acceptance and validation aspects of ABBT are 3uite consistent (ith man, nondirective- humanistic approaches to therap,- the behavioral elements of ABBT that re3uire si.nificant out-of-session activit, are not as common to these approaches. $t can be ver, useful for the clinician to *no( about a client4s previous e/perience and satisfaction (ith nondirective therapies as such a histor, can definitel, affect a client4s .oals and e/pectations for treatment. %or e/ample- Richard sou.ht treatment (ith one of us :Orsillo; after terminatin. (ith a humanistic therapist he had been seein. for appro/imatel, >? ,ears. At first Richard (as put off b, the su..estion that therap, (ould re3uire out-of-session (or*- statin. that he had done home(or* (hile he (as in school and he did not see the need for home(or* in therap,. $ spent considerable time (ith Richard in an effort to provide an ade3uate and compellin. rationale for out- of-session practice. A common clinical pitfall amon. bus, therapists is to rush throu.h the introduction of home(or* assi.nments (ithout providin. a sufficient rationale or ac*no(led.in. the challen.es of fittin. these tas*s into alread, bus, lives. Althou.h it is al(a,s beneficial for the therapist to ta*e sufficient time to tal* (ith a client about the challen.es of out-of-session practice- it is particularl, important to be sensitive to these issues (ith clients (ho have en.a.ed in a less structured and directive therap,.
$re(i"us E'&erience .in)fulness
with
As mindfulness- meditation- ,o.a- and other !astern spiritual practices become more popular in 2estern culture- more and more clients (ill present to treatment (ith some histor, of mindfulness practice. Such e/perience can be 3uite beneficial in preparin. clients to start ABBT- but sometimes clients have had ne.ative e/periences (ith these approaches that could interfere (ith ps,chotherap,. Once a.ain- as*in. clients to full, describe their previous e/perience (ith mindfulness- (hat the, li*ed and disli*ed about the practice- and successes and failures can be e/tremel, informative in the development of a rationale and plan for treatment. %or e/ample- Shoshanna- a client (ith features of dependent personalit, disorder- (as enthusiastic about ABBT because she thou.ht it (as consistent (ith her e/tensive sittin. meditation practice. Because the therapist assumed that Shoshanna (as e/tremel, *no(led.eable about mindfulness and the, (ere limited in the number of available sessions- she spent more time in therap, encoura.in. Shoshanna to en.a.e in valued actions than she did discussin. and practicin. mindfulness. 2hen it became clear that Shoshanna (as not ma*in. the .ains she had hoped for in
therap,- she and her therapist spent some time revie(in. their pro.ress and noted that Shoshanna (as stru..lin. si.nificantl, (ith the mindfulness concepts of self-compassion and acceptance. Because the therapist did not full, assess Shoshanna4s past e/perience (ith meditation- she (as una(are that Shoshanna had little practice (ith these s*ills.
TA+LE 2343 A))iti"nal Assessment Res"urces

Author:s; :,ear; Anton,- Orsillo< Roemer :>??6; 'ezu- RonanMeado(s< Mc+lure :>???; +ocoran < %ischer :>???; Association for +onte/tual Behavioral Science Buros $nstitute of Mental Measurements %orm Boo* &omain An/iet,
Reprints measur es )es
Boo*
&epression
)es
Boo*
Broad spectrum of ps,cholo.ical constructs
)es
2ebsite :www. 9ariet, of A+T-related contextualpsycho assessment instrumentslogy. org; includin. man, that currentl, under development 2ebsite :www.unl. edu'buros;
)es
"eneral and comprehensive listin. of 'o ps,cholo.ical instruments
ADDITIONAL ASSESS.ENT RESOURCES FOR T,E CLINICIAN

2hile (e have tried to describe the methods and measures (e thin* are most useful (hen conductin. a comprehensive assessment (or*in. (ith a client from an acceptance-based behavioral perspective- there are man, other assessment resources available to clinicians. A fe( boo*s and (ebsites that (e have found particularl, useful in helpin. us identif, and obtain assessment instruments are summarized in Table >.6. $t is also important to note that (e have been purposivel, overl, inclusive in our description of the potential measures and methods (e mi.ht use to conduct an assessment. 2hile all of these domains are important to assess(e believe that the therapist should choose instruments carefull, and fle/ibl, to meet the individual needs of different clients and situations.
FOR. 234
AN#IET/ AWARENESS S,EET
Please rate ,our an/iet, :on a scale of ? to 6??- (ith ? bein. no an/iet, at all and 6?? bein. severe an/iet,; at four different times durin. the da,. $f ,ou notice an,thin. (hile ratin. ,our an/iet,- feel free to Aot do(n these observations belo( the form. Ratin1 Scale-
? 'o an/iet, at all- completel, rela/ed Mornin . TimeDRati
@? Moderate an/iet,
6?? Severe an/iet,
&ate
'oon TimeDRati n.
!venin . TimeDRati
'i.ht TimeDRati n.
%rom Lizabeth Roemer and Susan M. Orsillo :>??=;. +op,ri.ht b, The "uilford Press. Permission to photocop, this form is .ranted to purchasers of this boo* for personal use onl, :see cop,ri.ht pa.e for details;.
@6
FOR. 232
@ >
E.OTION .ONITORING S,EET
2hen ,ou notice that ,ou are e/periencin. a stron. emotion- please ta*e a moment to notice and (rite do(n the situation ,ou are in and the emotion ,ou are e/periencin.. Please also record an, thou.hts ,ou are havin. at that time and an, ph,sical sensations :e...- heart racin.- muscle tension- fati.ue;. &ateDTime Situatio n !motio n Thou.ht s Ph,sical sensations
FOR. 235
ASSESS.ENT OF CO$ING STRATEGIES
As ,ou have been doin.- please continue to notice stron. emotions that emer.e in different situations and the thou.hts and sensations that accompan, each emotion. Also- note ho( ,ou respond to the emotion :e...- pa, attention to it- tr, and push it a(a,- distract ,ourself- tr, and chan.e it- etc.; and the outcome :successfulunsuccessful- feel better- feel (orse- etc.;. &ateDTim e Situation !motionsDThou.htsDSensatio ns Response Outcom e
@ E

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Mindfulness- and AcceptanceBased Behavioral Therapies in Practice

Lizabeth Roemer Susan M. Orsillo

Series Editors Note by Jacqueline B. Persons

T ! "#$L%OR& PR!SS 'e( )or* London

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' PRA+T$+!

+onceptualization of +linical 6 Problems = elements of these approaches- as (ell as traditional co.nitive-behavioral

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' PRA+T$+!

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' PRA+T$+!

RESTRICTED, ENTANGLED, FUSED INTERNAL AWARENESS Limits in Internal Awareness

Difficulties with the Awareness

ualit! "f Internal

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' PRA+T$+!

Reactivity to and Judgment of Internal Experiences

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' PRA+T$+!

+onceptualization of +linical Problems

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' PRA+T$+!

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' PRA+T$+!

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' PRA+T$+!

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' PRA+T$+!

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' PRA+T$+!

!/periential avoidance is a *e, part of an acceptance-based behavioral

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' PRA+T$+!

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' PRA+T$+!

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' PRA+T$+!

+E,A%IORAL CONSTRICTION FAILURE TO ENGAGE IN %ALUED ACTION

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' PRA+T$+!

GOALS AND .ET,ODS OF INTER%ENTION

+onceptualization of +linical Problems clarif,in. internal a(areness

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' PRA+T$+!

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' PRA+T$+!

+linical Assessment of Relevant &omains

S/.$TO.0+ASED ASSESS.ENT +r"a) O(er(iew "f $resentin1 C"ncerns

B PRA+T$+! FIGURE 2343 &ere*4s problem list.

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $'

+linical Assessment of Relevant &omains

+linical Assessment of Relevant &omains

+linical Assessment of Relevant &omains

+linical Assessment of Relevant &omains

RELATIONS,I$ TO INTERNAL E#$ERIENCES Awareness "f Em"ti"nal E'&erience

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $'

+linical Assessment of Relevant &omains

C M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $' B rated on a PRA+T$+!

+linical Assessment of Relevant &omains

Fusi"n with E'&eriences

Distress Relate) E'&eriences

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $'

+linical Assessment of Relevant &omains

CURRENT AND $AST CO$ING STRATEGIES General C"&in1 Strate1ies

S&ecific .easures "f E'&eriential A("i)ance

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $'

+linical Assessment of Relevant &omains

M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B! A9$ORAL T !RAP$!S $'

+linical Assessment of Relevant &omains

UALIT/ OF LIFE D"mains "f Functi"nin1

$re(i"us E'&erience .in)fulness

TA+LE 2343 A))iti"nal Assessment Res"urces

Reprints measur es )es

Broad spectrum of ps,cholo.ical constructs

"eneral and comprehensive listin. of 'o ps,cholo.ical instruments

ADDITIONAL ASSESS.ENT RESOURCES FOR T,E CLINICIAN

AN#IET/ AWARENESS S,EET

? 'o an/iet, at all- completel, rela/ed Mornin . TimeDRati

6?? Severe an/iet,