ACT Now

Adjusting to Cancer
Committing to your values
Taking action now

Therapist Manual:
Individual Therapy

Linda Bilich , J. T. Blackledge, Joseph Ciarrochi, and Danielle L Feros, Lisbeth Lane
(note: authors listed alphabetically, not in order of contribution)

University of Wollongong Dr Kendra Sundquist

Cancer Council, NSW
 Contents
Hints for running therapy sessions...................................................................................3
General session structure..................................................................................................5
Initial contact with clients.................................................................................................7
MODULE 1 - Letting go of unhelpful struggle, Making room for living...................10
MODULE 2 - How we get stuck in our minds and lose sight of our life as it’s
happening now.................................................................................................................22
MODULE 3 - You are more than your pain; You are more than your suffering;
You are more than your cancer......................................................................................27
MODULE 4 - Moving toward a vital, meaningful life---with your pain....................30
Metaphors...........................................................................................................................x
Barriers to life enhancement exercises.............................................................................x
Useful references................................................................................................................x

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 Hints for running therapy sessions

1. The ultimate goal is workability. We help the client find what works. One way to tell
something is working is if it helps the client to move in their valued direction.

2. We are all in the same boat. All of us suffer and struggle. All humans tackle a similar
set of problems. Therefore, as a therapist, never try to protect yourself by moving one up
on the client.

3. We are not trying to fix the client. They are not broken.

4. We minimise persuading. We don’t want to convince clients of our beliefs. Ultimately

it does not matter what we believe. It is the experience of the person that is important. We
want people to convince themselves using their own experience.

Therapist: Tell the client to not believe a word you are saying. They should trust
their own experience, rather than what you say.

5. Be passionately interested in what the client wants.

6. Have humility. We are all fallible human beings. We will all make mistakes. If we
accept this, we will be more open to learning from our mistakes and improving the
intervention.

7. The therapist should not supply all the energy and ideas about how to make things
better in the client’s life. The client needs to be actively involved in all aspects of the
session.

8. We will be using many metaphors in this therapy. The therapist should not simply read
the metaphors out loud. Rather, they need to be related to the client’s experiences.

9. Be patient. Create room for experiential sessions. Inform the client that there may be
times when a session seems unstructured. Also, that a range of feelings might show up for
the client, including confusion and frustration, and that it is okay to have these feelings,
and to remain engaged / involved in the session.

10. Seek to establish a climate of trust, acceptance, and safety through

a) Identifying and communicating your values and commitment to the client
b) Responsiveness and attentive listening
c) Communication of understanding, liking, and respect
d) Model both acceptance of challenging content and a willingness to hold
contradictory or difficult ideas, feelings or memories
e) By asking the client for permission when engaging in exercises

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 f) and, be willing to self disclose about personal issues when it makes a
therapeutic point.

11. Prepare yourself for resistance. Try to be present with what shows up for you when
this happens. Someone might tell you that you don’t know what you are talking about,
that you can’t possibly understand them unless you have had cancer. Notice the things
you feel pulled to do (maybe you want to put them down, stand over them, or reject them
in some way). Notice how you are feeling. Then, do what works. What is the valued
direction you want to put into play in the session? What action can you take, in this
moment, to move in that direction? Usually, it is a bad idea to meet resistance with
resistance. Practice rolling with resistance and see how that works.

12. Be accepting of whatever shows up. Do not judge. Avoid coercion. Do not argue with,
lecture, coerce or attempt to convince the client of anything. Remember, the sessions are
in the service of their values, not ours.

13. Remind the client that the workbook they are given contains experiential exercises.
These exercises are designed to help them to get in contact with what they experienced in
the session rather than provide a first-time experience.

14. Remember to highlight exercises in their workbook that they can do on their
own as practice exercises. Discuss the advantages of practicing. You may want to
emphasise that practicing may require as little as just a few minutes a day. Discuss
barriers to practicing (see back of manual).

15. NOTE TO THE INDIVIDUAL THERAPIST - This manual is a guide for session
structure only. It is important to be flexible in your use of this protocol. Use
whatever the client brings to the room. This may include, for example, discussing
values at multiple times during therapy and not just during the suggested sessions.
The use of each technique and metaphor listed in each session is not necessary. Only
use what comes readily and more importantly tie each into what the client is
experiencing in the present moment.

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 General session structure

Generally, therapy sessions should follow the structure outlined below (taken from Hayes
et al., 1998):

Review

1. Begin each session with an experiential centring exercise. The purpose of these
exercises can be explained as to (1) help the client and therapist be more ready for new
experiences, (2) help the client become better at just noticing what they experience, (3)
set aside the clutter of day-to-day mindstuff and get the client and therapist “in the room”,
and (4) focus the client and therapist on their shared task.

2. Review the client’s experience since last session. Inquire about any reactions to
material from the previous session.

3. Inquire about any completed life enhancement exercises and about reactions to any
theses. If the life enhancement exercise has not been completed explore barriers to doing
this. Barriers should always be received in a nonjudgmental fashion. They should always
be viewed as opportunities to examine the workability of whatever strategy the client
used. Always remember that we will not serve the role of prosecutor for the client’s
crimes. We should always take the position that if an agenda is unworkable, the client’s
life will let us know. The client does not need one more person in his or her life telling
them what they ought to do. In addition though, never takes client’s portrayals of reasons
for doing something that does not work literally. Under no circumstances should you
pretend, along with the client, that the unworkable is somehow workable if the reasons
are sufficiently compelling.

4. Inquire about ways in which in-session material is impacting life functioning (e.g.,
intrapersonally or interpersonally in interactions with others at work, home or in social
situations).

New material

Following the above review, new material should be introduced. Some core topics may
be covered in a single session; however, others may take several. The core topics should
be done in sequence. More flexibility is acceptable as more topics are introduced. Ideally,
the new material will be integrated with examples from the particular client’s life.
Actively support the client in connecting new material with the client’s life experience.
Remember that ACT is aimed at disrupting problematic aspects of the verbal regulation
of behavior. In other words, the point of therapy is not to introduce a different set of
regulations. The client’s life experiences are solicited in connection with these topics

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because we want the client to carefully examine and be guided by their own experience,
rather than some new and “better” system of rules and beliefs.

Life enhancement exercises and behavioural commitments

Various topics contain life enhancement exercises. Many life enhancement exercises can
be found in the ACT Workbook. Some topics will also contain suggestions for behavioral
commitments on the part of the client.

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 Initial contact with the client

During initial contact with the client, spend time building rapport and hearing about their
struggle. The following information about the therapy you will both take part in should
be discussed. At the end of the session, obtain a commitment from the client to begin
ACT Now individual therapy sessions.

Informed consent

Referral
Discuss with the client the nature of the referral and their understanding of why they are
here and what kinds of things will be done in therapy.

Research project (where applicable)

Discuss briefly with clients what the research project is about. Explain the randomised
design; explain the nature of ACT therapy: “Helping you to live a full, vital life. Can you
live a vital, value driven life, with your pain, with your distress?”. Explain the supportive
psychotherapy structure. Explain that therapy will consist of 9 hours of face to face
contact with the therapist; individual 9 x 1hour sessions, group 3 x 3 hour sessions.

Confidentiality
Explain that any personal information that is revealed or discussed in this or any session
is confidential and will not be shared or discussed with anyone at all outside of the room
(including partners and family members).

Freedom to discontinue
Explain that they are free to leave this or any subsequent therapy session at any time and
for any reason, and the fact that they have left will not be reported to anyone.

Audio recording
Explain that the therapist’s voice will be recorded during the session to ensure therapist
adherence to the intervention. Explain that this is quality assurance for the client. Every
attempt will be made to capture only the therapist’s voice by placing the microphone
close to them.

Measures
Advise clients that they will be required to complete some measures which will provide
information about the changes they are making to their lives during therapy. Explain the
times the measures will be taken and as necessary go through the measures to be used.

ACT NOW intervention ( taken from Blackledge, 2006)

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Begin explaining that this course of therapy will be about two things. Firstly, it will
involve helping them with the things they struggle with—distressing feelings that come
up for them, tough situations they have a hard time facing. This will include teaching
effective behavioural strategies to increase their ability to deal with distress. Second, and
most importantly, therapy will be about helping them get more of what they really want
out of life. It’s important that they understand that this means therapy will primarily be
about them getting more of what is really important to them out of life.

Explain that over the course of therapy you will be essentially asking clients to repeatedly
and willingly focus on intensely aversive experiences they have been attempting to avoid
as a matter of course. Thus, it is critical that they consent to this process, described
roughly as follows. Promise them that you will make this therapy be entirely about
helping them get more of what they really want out of life—that you’re committing to
work as hard as you can toward this goal. Let them know that, in therapy, you sometimes
feel worse before you feel better. Deliver the Cleaning Mud from a Glass and/or Roller
Coaster, metaphor. Check for the client’s understanding of what you mean by the
metaphor. Then ask them, given that they understand this process will be painful at times,
but that there’s a real possibility that they will have more of what is really important to
them in life as a result, if they’re willing to commit to doing this therapy. Promise that,
every time you as them to focus on a painful feeling or experience in therapy, it will
always be in the interest of helping them move toward what’s most important to them.

Make the clients aware that treatment will be very interactive and experiential, which
means that you will frequently ask the client to engage in activities both in and out of
session. Consistent with ACT’s heavy emphasis on valued living, the home activities
should be conducted within the context of client’s personal values and life goals. Clients
will ultimately be responsible for making the choice to do such exercises and will be
more likely to do so if the assignments are consistent with what matters to them. It’s
important to remember that the goal of treatment is for clients to show improvement in
real life. In-session exercises are merely designed to prepare clients for making important
life-enhancing choices where it really counts – in the real world, outside of the therapy
room!

How to get the most out of therapy

Therapists should say the following to the client:

Stay open to experience

Stay open to what we’ll be discussing and the exercises I’ll be taking you through.

Participate
Participate fully in the session, particularly in the experiential exercises we’ll be doing.
It’s the nature of this approach that you only really learn it by doing it. Listening to what I
have to say is a good start, but taking a good honest stab at the exercises is essential for
getting something out of this. The best way to understand this approach is to do it. I’d
encourage you to share some of the things that come up for you when I ask.

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Stay present
Stay in the room (physically) during sessions. Sometimes during some of the experiential
exercises we’ll be doing, you may have some potent emotional stuff come up for you.
Sometimes people get the urge to leave the room, so that they can compose themselves or
distract themselves. I’m going to ask that you do not do that for the simple reason that if
you do, you will miss out on a golden opportunity to practice exactly what we’re doing
here in the midst of that potent emotional stuff. If potent emotional stuff shows up for
you, stay with it in the manner that we’ll be discussing, and you’ll get far more out of the
experience.

Be patient with confusion

It’s about your experience. It will gradually unfold.

Committing to therapy

Tell the client that you, as a therapist, are committed to helping them live a life that is in
the valued direction that they choose. Ask the client to commit to doing this with you
over the next 9 sessions, even though it will involved facing some painful and distressing
emotions that they have being trying to avoid until now.

At this point, consent forms and measures should be completed if they haven’t already.

Pre-therapy measures

Ask the client to complete the first measures prior to therapy commencing. Clients may
wish to take the measures home and bring back completed to the first therapy session.

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MODULE 1 – Letting go of unhelpful struggle, making
room for living
This module (2 – 3 sessions) aims to cover the following areas:

 Initial values assessment

 Challenging the normal change agenda: Creative hopelessness
 Control is the problem, not the solution
 The alternative to control: Willingness

Review

Explain to the client that each session will begin with a mindfulness or ‘centring’
exercise. Explain the aims of the centring exercises (p. 5 of this manual). Then, deliver a
centring exercise. Link the mindfulness/centring exercises with the content of last week’s
and this week’s sessions. Explain how this session will further explore the processes of
the mindfulness/centring exercise.

Example centring exercises include:

 mindfulness of the breath/sounds/sensations
 mindfulness of thoughts/emotions
 mindfulness of thoughts/feelings that the client struggles with
 mindfulness of control strategies
 willingness to sit with uncomfortable thoughts/emotions

Review (see p.5 of this manual) the last session with the client as well as their life
enhancement exercise during the week. Acknowledge any effort the client has made at
engaging in the life enhancement exercises including monitoring of
thoughts/feelings/emotions/valued-living/suffering that may not have been written down.
Highlight the degree of suffering the client endorses and how hard they are trying to deal
with these tough thoughts and feelings. Further highlight the controls strategies used by
the client and identify the cost of theses control strategies. Acknowledge any valued-
living moves and highlight the client’s ability to do what is important to them in spite of
unpleasant thoughts and feelings.

Initial values assessment

(taken from Blackledge, 2006)

Values assessment begins early in this protocol to maximize the chance that the client will
be motivated to engage in treatment, to minimize treatment resistance by declaring early
and often (in word and in deed) that this treatment is about helping the client get more of
what he/she most wants out of life—not about ‘behaving more reasonably’, doing what
they ‘should’ do, or other things that involve the potential imposition of someone else’s
agenda upon them. The risk of conducting a values assessment prior to defusion and
acceptance work lies in the fact that endorsed values, at this point, have a lower
likelihood of being genuine. That is, without developing tools to ‘unhook’ from social

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prescriptions about what values ‘should’ look like, clients are more likely to endorse
values that reflect social norms rather than personally vitalizing preferences.
Additionally, endorsing a genuine value that one has consistently failed to move forward
on can be emotionally painful. Thus, it can be difficult for clients to vocalize a value if
doing so brings pain and guilt about their relative failures in living this value ‘into the
room’ for them. As a result, formal values assessment will continue again later in the
protocol, after significant defusion & acceptance work has been done. Further, remain
alert in every session toward signs that endorsed client values may reflect the standards of
the client’s friends, family, broader social network, and culture rather than reflect
heartfelt desires from the client about how she most wishes to live her life. Additionally,
stay alert to any influence (intentional or unintentional) you may be having on the client’s
values. It is easy for a client to want to please a therapist by adopting values she believes
will meet with approval with the therapist. Similarly, it is easy for a client to adopt values
she believes might shock the therapist or otherwise meet with disapproval, perhaps as a
way of exerting her individuality.

When beginning the initial values assessment, remind client that the ultimate goal of this
therapy is to help her/him do more of the things that are really important to her/him—
more of the things that really matter to her/him. DEFINE VALUES IN A USER-
FRIENDLY WAY. Values are about living and acting in ways that imparts vitality &
meaning to one’s life, regardless of whether others are impressed, regardless of whether
others approve, regardless of whether one feels better about oneself, regardless of
whether such values makes one ‘a good person’, etc. Only the areas important to the
client should be focused on.

It’s very important, before conducting a values assessment, to make sure the client
understands that this is all about what they value, regardless of what they think they
should value, what their friends or family value, what society values, or what they think
you (the therapist) values. Tell them they’re free to talk about any kind of value they
want to—that you won’t try to convince them to value something else. You have a few
options for how to conduct the values assessment:

1. You may refer to the values assessment that the client completed as part of the
pre-therapy measure.
2. Ask the client to imagine they are at their birthday party. All the important people
in their life are there and some are going to get up and say something about them.
Ask the client what they would hope for people to say about the type of person
they are (e.g. as a parent, child, friend, partner, colleague, etc).
3. The ‘sweet spot” exercise. For clients who have great difficulty clarifying values
you might try asking them to recall a few of the best moments they’ve had with
friends, family members, and partners (focus on one category at a time). Ask them
to describe each situation in some detail, and describe what was happening there
that they really liked. What was the other person doing that was great? What was
the client doing that was great? Try to zero in on the qualities of the interaction
(e.g., was the client and/or the other person being caring, considerate, kind,
trusting, etc.?). Once there is some clarity about these qualities, ask the client if

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 he/she would like to have more interactions like that—if moments like that define
the kind of friend (or daughter/son, brother/sister, partner, and so on) they most
want to be—if those kinds of interactions define the kind of friendships/family
relationships/boyfriend-girlfriend relationships they most want to have.

Sometimes the client endorses values that are restrained by what they think is possible
given their current, rigid conceptualizations of their circumstances. Thus, it’s often
helpful to preface domain-specific values queries with questions like “In a world where
you could have exactly the kind of relationships you wanted, what would your
relationships look like?” Or, “in a world where anything was possible, what kind of
interests or jobs would you like to work toward?”

If clients give apparent values that appear unrealistic (e.g., “I want to be a movie
star….astronaut…. professional athlete….rich……” there are at least a couple of possible
directions to go. One, you might ask the client how their life would look different if they
achieved that. What would they be able to do that they can’t do now? What kind of
friendships would they have? What kind of relationships? Would some of the problems
they have go away if they had that? And so on…. Two, you might assess to see if there is
something within the professed ‘value’ that they get intrinsic enjoyment—vitality—out
of. It may be, for example, that someone who wants to be a movie star loves performing,
or that the aspiring pro athlete gets an honest charge out of sport. Ask questions like
“what do you like most about doing x….” to determine what aspects of the apparent
‘value’ they can put into play now, regardless of what efforts toward the ‘value’ may or
may not culminate in down the road.

Remember, the ACT take on values defines them as unilateral actions people can take
that have a relatively high likelihood of producing the kind of outcomes they want. Thus,
a “close friendship” would be accepted as a good starting point in values assessment, but
the focus would then shift to what kind of qualities and actions the client feels is most
important to bring to bear in order to build that kind of friendship. To help the client zero
in on these things, you might ask some of the following questions:

1. What are the qualities you most like in a close friend?

2. In the past, during times when you felt close with a friend, what kinds of things
were you doing that you think helped build that closeness?
3. What do YOU think are the most important qualities of a close friend? Not what
others think—what do YOU think?
4. At a gut level, what ways of acting toward a close friend just feel right to you—
just send kind of a chill up your spine, or make you feel more alive, more vital.

Once a client has endorsed an apparently ACT-consistent value, it’s important to make
sure it is actually THEIR value, rather than someone else’s (yours, parents, society’s,
friends, etc.). Thus, it is often helpful to ask questions like:

1. “Think very carefully about this before you answer…..If no one ever knew that
you valued that, would you still want to do it?”

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 2. For values that involve finite outcomes (e.g., ‘getting a college education’), ask
something like “Imagine you worked toward a college degree, and the day after
you got it, it was taken away. Would you still value getting a college education?”
‘No’ answers may tip you off to the fact that the apparent ‘value’ is actually in
service of another value (e.g., ‘having a career in a helping profession’), is
actually a ‘value’ endorsed to impress others or prove one’s worth, etc.

Challenging the normal change agenda: Creative hopelessness

(taken from Blackledge, 2006; Hayes et al., 1998)

The purpose of this section is to challenge unproductive attempts to avoid or otherwise

control physical and emotional pain. This first involves helping clients to identify the
ways they have tried to control their feelings. It will be important to identify the difficult
thoughts / feelings that the client is struggling with and to ask the client about the control
strategies they use to fix / get rid of / lessen their distress. Ways to do this include:

 Normalize the client’s distress and efforts to manage distress

 Identify patterns of cognitive, emotional, & behavioural avoidance/control
strategies
 Introduce the client to the ‘rule of public and private experience’
 Evaluate the short- and long-term workability of these strategies
 Appeal to client’s direct experience to determine whether a particular strategy
“works”
 Recast the “distress problem” as one of unworkable change agendas
 Instil hope by emphasizing that the client is able to respond differently

It is important to be non-confrontational, particularly when asking how the control

strategies have been working. Approach this section with a curious stance – you simply
want to know how these things have been working for them and if the client is adamant
that they have worked, then that is okay too.

The following questions may be asked to illicit the client’s struggles, and their control
strategies:

 What are the difficult and / or distressing emotions / thoughts that they are
struggling with?
 How long have they been struggling with this?
 What have other people told them about how to control their distress, or get rid of their
difficult thoughts / emotions?
 What are some of the more destructive things people do to reduce their distress?
 What have you tried to do to make your distress go away, or to control difficult thoughts
and feelings?

Ask the client ‘How well have these strategies worked for you?” (short and long term
workability). The purpose of this next step is to assist the client in evaluating the extent

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to which past change efforts have worked in various domains. For example, does the
client’s experience suggest that attempts to avoid or escape private experiences genuinely
lead to no distress (or even less distress)? Have attempts to control pain helped the client
to create a rich and meaningful life? The purpose of this discussion is to review the
workability of past solution attempts. It is not whether these efforts were right or wrong.
It is about whether they have worked in the long run in terms of enhancing the client’s
life, making it more vital and rich.

Note: If the client endorses the use of problematic strategies, ask them “Has it worked
fundamentally in the way that you really want?” and/or, “Are there any downsides? Does
it work in the short run, but not in the long run?”

Next, explore the personal costs of efforts to control private experiences. For example,
how has the struggle with distressing private experiences restricted or limited the client’s
life?

When exploring personal costs, you might ask the client:

 How has this impacted on your life?

 What has this cost you (physically, emotionally etc.)?
 What have been the long-term costs of struggling with distress?
 What have you given up for your distress?
 What has happened to your life over time? Have you done more or less with your
life?
 Have your options increased or has your ‘life space’ narrowed over time?
 What would you do with your time if it were not spent trying to manage distress?
 In a world where anything was possible, what would your life “look like?” What
would be different?
 If this were a free choice and anything were possible, is this the life you’d choose
for yourself? What would be different?
 In a world with no distress, how would your life be different? What would it look
like? What would you be doing?

After reviewing costs of trying to manage distress, an explanation such as the following
should be provided:

You have tried to do everything that is logically there to be done. You’ve tried all the
obvious things to get rid of your distress. And what does your experience tell you about
how this has worked? Are you still struggling with your private experiences? Have you
experienced big costs in trying to manage or deal with your distress? It just doesn’t make
sense. You’ve tried really hard to get unstuck… to make the pain go away. And yet, isn’t it
the case that, in your experience, all this hard work and struggle has not paid off? It’s
like your mind is telling you, “I have pain; I don’t want this pain, so I’m going to get rid
of it.” And what does your experience tell you about how this seemingly logical plan has
worked? Perhaps we need to consider the possibility that maybe it hasn’t worked – not
because you aren’t clever enough or haven’t tried hard enough – perhaps it hasn’t worked

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because it CAN’T work. It’s like a rigged system – a trap. Perhaps you’re caught up in a
totally unworkable system that simply can’t work. You’ve done all the rational, smart,
obvious, logical things and yet here you are. The distress is still here, and it’s costing you
big time.

Consider the possibility that if you do more of the same, this is exactly what you’ll get.
I’m asking you to consider the possibility that perhaps your very efforts to solve the
problem may actually be part of the problem. Maybe what has always looked like a good
and logical solution is not the solution at all. It may actually be part of the problem, or
perhaps even the problem. I’m not trying to make a logical point here, and I’m not asking
you to believe me. In fact, I suggest that you don’t believe a word I’m saying. Instead,
check in with your experience and honestly evaluate (based on your experience) how
attempts to manage pain have worked. Your experience tells you that these attempts to
control your private experiences hasn’t worked, yet your mind keeps saying “There has
got to be a way out”. I’m here to ask you: which are you going to believe, your mind or
your experience?

The discussion of past experiential avoidance/control efforts is likely to reveal that the
old solutions have not worked and have come at considerable personal costs.
Hopelessness in this context is about helping the client to experience that past solutions
have not worked, and will not work in the future, because they cannot work.
Hopelessness is about contacting the un-workability of past distress management
strategies; it’s not about giving up or giving in to despair. At this stage, it is important to
resist the temptation to console or motivate the client by reassuring them that “things will
get better” or “everything will be alright.” Hopelessness can be motivating if it becomes
creative, and what makes hopelessness creative is the emphasis on the hopelessness of
past solutions and that these solutions are hopeless, not the client. This emphasis implies
that there is hope if the client chooses to adopt a different approach to living with their
private experiences and distress. The Man in the Hole metaphor can be used to illustrate
the unworkable nature of the client’s struggle with distress.

At this point clients may ask you for the way out of the hole. In this case, you might say
something like:

“Your job right now is not to figure out how to get out of the hole. That is
what you have been doing all along. Your job is to accept that you are in
one. In the position you are in right now, it wouldn’t do any good if you
suddenly discovered a ladder. You’d only try to dig with it. You can’t do
anything until you let go of the shovel, and make room for something else
in your hands. And that is a very difficult and bold thing to do. The
shovel appears to be the only tool you have. Letting go of it looks as
though it will doom you to stay in the hole forever. And I can’t really
reassure you on that. Your best ally is your own pain, and the knowledge
that nothing has worked.”

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The client might ask what they should start doing differently. It is important to tell them 
not to change anything and just focus on observing when and how they “dig”. You may 
instruct the client to simply notice (and record) how they deal with physical and 
emotional pain when it occurs and how well their control strategies work.

At the beginning of each session in this module, the client’s life enhancement exercises
can be drawn upon to recast the “distress problem” and any ineffective and destructive
attempts to control private experiences (e.g., thoughts, emotions, physical-bodily
sensations). In this way, the client’s unworkable struggle with emotion (rather than
emotion itself) is conceptualized as the problem. Pointing to the wisdom of the client’s
direct experience, note how attempts to gain control over pain may paradoxically result in
a loss of control over one’s life.

To illustrate the paradox of control, use a metaphor such as the Chinese Finger
Trap, Quicksand, or Tug-of-War with a Monster metaphor. These can be useful as
supplements, when the client needs additional ways of connecting with the issue, or as
quick introductions useful in the earliest parts of treatment. These metaphors capture,
very quickly, the essence of the client’s situation. They point to the possibility that there
is a counterintuitive solution to their problem. They make contact with the lack of
workability of common sense, logical solutions in some contexts. This is important,
because the metaphors themselves provide a kind of reality check: things can sometimes
be like this.

Control is the problem, not the solution

This section aims to further explore the areas of life in which control strategies do not
work. Client’s life enhancement exercises can be used to review unhelpful control
strategies. Link the unworkability of the client’s control strategies and their cost with
discussions/exercises about:

 Feeding the Tiger metaphor: Shows clients that trying to deal with pain by giving
into pain’s demands often has paradoxical and harmful effects. It also
demonstrates how increasingly larger portions of the client’s resources and life
space can get eaten up by efforts to control and avoid pain

 We are taught to control our “bad” feelings and thoughts (p. 7): Return to creative
hopelessness – discuss the predominant view in culture about ‘feeling good’
‘thinking positively’ etc. Ask the client about their experience.

 Exercise: Does control work? (p.9): Link to discussion about their own control
strategies that they have been using to get rid of / change their distress (life
enhancement exercise). Use the Yellow Jeep (or Chocolate Cake) exercise (p. 12)
as an experiential exercise to demonstrate the futility of trying to control thoughts
(Audio Track 1: Does Control Work?).

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  Exercise: Don’t be anxious…or else! (p. 13): The futility of controlling emotions.
Use the Polygraph metaphor to demonstrate the inherent difficulty in changing /
getting rid of emotions.

 Exercise: Think positively, now! (p. 14): Positive thoughts often tend to pull in
negative thoughts. Refer to the way in which the mind pulls from both extreme
positive and negative thoughts.

 Exercise: Don’t think about your thoughts (p. 14): Discussion how trying to
control/avoid thoughts often means we have the thought even more – if you don’t
want it, you got it! Discuss how allowing thoughts to come and go means that
while the unwanted thoughts may show up, there is room for other thoughts too.

 The rule of public vs. private experience (p. 15): This is not about giving clients
another rule to follow, but for them to experientially get in contact with the futility
of ‘controlling’ distress. Lead into discussion about the counterintuitive nature of
this ‘rule’.

 If trying to control our thoughts and feelings doesn’t work, why do we do it? (p.
16): Link this section with the first point. ‘Suffering’ is part of life, and it is
something that we will all struggle with at some point.

 Revisit the Quicksand or Tug-of-War with a Monster metaphor to capture the

essence of the client’s situation and point to the possibility that there is a
counterintuitive solution to their problem.

 Use a mindfulness exercise to get the client to check with their own experience
about how unworkable control strategies can be with regard to private experiences
(Audio Track 2: The Alternative to Control…. Willingness).

The client might ask, “So, what am I to do?” At this stage, it is not necessary to be
specific as to what this different approach might look like. You may have some ideas
about what might be done to help a client get unstuck and move forward or may have
concerns about coming across as dismissive of the client’s suffering. These are legitimate
issues. The aim of these sessions, however, is to explore the un-workability of past
change efforts with the client. The client needs to experience and come into direct contact
with the un-workability of past control agendas, and as the therapists you must guard
against trying to “rescue” them by providing just one more “quick fix.” Thus, when the
client asks “what am I to do?” you might respond by saying something like “there is no
simple answer as to what exactly will work for you. What we don’t want to do is go down
the same old road that got you stuck in the first place.” Therapists can express optimism
that creative solutions on the path to living will emerge from this process without going
into too much detail at this point.

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 The alternative to control: Willingness
(taken from Blackledge, 2006, Hayes et al., 1998)

ACT undermines experiential avoidance and control and encourages an active and
ongoing acceptance of private events, referred to in therapy as “willingness.” Instead of
presenting the client with more sophisticated distress management strategies (e.g.,
cognitive restructuring, progressive muscle relaxation, imagery), ACT techniques
promote a thoroughgoing willingness to experience private events as they are. At this
early stage of therapy, willingness is simply introduced as an alternative to controlling
private experiences. Initially, the client may find the concept of willingness difficult to
grasp. This is not problematic because the nature and quality of willingness is explored
and practiced throughout the course of treatment (in some ways, this is the treatment).

After demonstrating the paradox of control and pointing to areas of life where control
does and does not work, introduce willingness as an alternative to futile control strategies
(e.g. using the Chinese Finger Trap or Tug-of-War with a Monster metaphors). The
nature and qualities of willingness will be explored in future sessions and is only briefly
presented here. You should aim to cover several points about willingness, providing
examples and clarification as needed:

 Willingness is an alternative to unworkable control efforts

 Willingness is the active process that involves opening ourselves up to our experience
and allowing ourselves to have what we already have (this does not mean that we
want, like, or seek out pain)
 Willingness is experiencing our experience when we experience it (!)
 Willingness involves experiencing fully, without struggle or defence
 “Dropping the rope” is an act of willingness (Tug-of-War with a Monster)
 Leaning in rather than pulling out is an act of willingness (Chinese Finger Trap)
 Willingness is not the same as “wanting,” nor does it imply passive resignation or
mere tolerance
 Willingness involves simply noticing and being present to whatever shows up in the
world beneath our skin
 It may be helpful to provide the client with the following formulation to demonstrate
the nature of willingness: Pain + Unwillingness = Suffering or Trauma

Refer to The alternative to control: Willingness (p. 19): Are you willing to have
distressing thoughts and feelings, as they are, not as what they say they are, and still do
what matters to you…live your values and goals? Willingness is a choice, and an action.
It’s not about liking, or giving in. It’s about having distressing private experiences in
order to live a vital life – whatever you choose that to be.

Follow up this with discussions about:

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  Quicksand metaphor (p. 18): A metaphor that reflects the rule of private
experience. It seems counterintuitive to stop struggling and yet this is what is
most effective.

 The Chinese Finger Trap (p. 22): What does it feel like to be ‘stuck’? Moving
into the finger trap creates ‘wiggle room’, or flexibility to do something different.

 The Two Scales (p. 23): Our distress comes and goes and it can be high and low.
Struggling to control these usually leaves us with more distress. Choosing
willingness is about having this distress, whether it is low or very high, and not
engaging in the useless and traumatic struggle that comes with controlling private
experience.

 The cost of unwillingness (p. 34): What is the cost of being unwilling to
experience your distress? What areas of your life have been affected? Talk about
‘pain’ and ‘suffering’ and the concept of ‘clean discomfort’ and ‘dirty discomfort’.
When we buy into our ‘dirty discomfort’, what does this cost us?

 Use a mindfulness exercise to get the client to check with their own experience
about how unworkable control strategies can be with regard to private experiences
(Audio Track 2: The Alternative to Control…. Willingness).

 Use Willingness exercises to help the client experience willingness as an

alternative to control. These may include:

o Noticing different aspects of unpleasant private experiences (e.g. location

in the body) and staying with them
o Willingness and acceptance of unpleasant emotions through
physicalisation

Life enhancement exercises

Throughout this module, a number of different life enhancement exercises may be used,
depending on where the client is at and what their needs are. Use the following as guide
to help you determine which exercises will be appropriate for different clients.

Initial values assessment

 Have clients complete the Personal Values Questionnaire which can be used to
facilitate initial discussions about values
 Ask clients to write down personal qualities that are important to them that they
believe they have or would like to have more of

Challenging the normal change agenda: Creative hopelessness

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  Ask the client to notice any private experiences that come up during the next
week that they would rather not have and the strategies they use to avoid or
change these (the types of ways they try to dig). Ask the client to record these (p.
11 of the client workbook) and then rate how effective the strategies were at
alleviating distress (both the short and long term effects).

Control is the problem, not the solution

 Ask the client to listen to “Track 1: Does control work?” between sessions.
 Ask the client to look for a few uncomfortable moments that occur during the next
week and record impressions as asked for in the Daily Experiences Diary (p. 32).
Reiterate that this exercise is not going to change anything; it is an attempt to
gather important information about the scope and content of the client’s struggle.
The most important part of this assignment is to help the client see how each
coping strategy used to address an uncomfortable experience did or did not
incorporate a control and eliminate philosophy.

The alternative to control: Willingness

 Ask the client to complete the willingness exercise part 1 (p.24) with any of the
emotions listed that are relevant for them. Have them notice their dominant
negative experiential states (e.g. anxiety, sadness, anger), their willingness to have
these, and the workability of his or her approach to life during that day. Ask the
client to make notes about any interesting or unusual experiences that seem
connected with higher rating of willingness/struggle and/or workability, or
conversely, observations about processes that seem to heighten negative states and
suffering.
 Ask the client to listen to “Track 2: The alternative to control…. Willingness”
between sessions.

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MODULE 2 - How we get stuck in our minds and
lose sight of our life as it’s happening now

22
This module (2 – 3 sessions) aims to cover the following areas:

 Defusion
o Defusion exercises
o The mind is a “don’t-get-eaten machine”
o Mindfulness

Facilitator: This module relates to fusion and defusion from distressing thoughts /
evaluations. Link the previous section with a discussion about being willing to look at
these distressing thoughts etc. and defusing from them in the service of living our values.
It is important to emphasise to participants throughout this section that we don’t want
them to believe what we are saying, but rather to look to their own experience. Keep
saying, ‘Don’t believe anything I say”.

Review

As in the previous module, begin each session will begin with a mindfulness or ‘centring’
exercise. Explain the aims of the centring exercises (p. 5 of this manual). Then, deliver a
centring exercise. Link the mindfulness/centring exercises with the content of last week’s
and this week’s sessions. Explain how this session will further explore the processes of
the mindfulness/centring exercise.

Example centring exercises may include:

 mindfulness of thoughts/emotions
 willingness to sit with uncomfortable thoughts/emotions through noticing or
physicalisation
 “leaves on a stream”, “clouds in the sky”
 a mindfulness exercise to get the client to experience what being unwilling can be
like (e.g. Passengers on the Boat).

Review (see p.5 of this manual) the last session with the client as well as their life
enhancement exercise during the week. Acknowledge any effort the client has made at
engaging in the life enhancement exercises. Highlight the use of controls strategies used
by the client and identify the cost of theses control strategies. Acknowledge any
willingness moves where the client has been accepting of unpleasant thoughts or
emotions in order to move toward something important to them.

Defusion
(taken from Blackledge, 2006)

The purpose of the defusion sessions is to facilitate acceptance of unpleasant emotions

and thoughts by exposing the language-based processes that enhance suffering. At a
fundamental level, unpleasant or aversive emotions have no power to harm us—emotions
are not dangerous in and of themselves. Emotions appear dangerous—and drive people
to experientially avoid in ways that can be both harmful and counterproductive—because

23
we believe they are dangerous. Cognitive defusion strategies help break down these
literal beliefs by exposing the arbitrary nature of language—by exposing its ‘illusory
qualities’, its ‘shallowness’, its inability to capture direct experience. Use of defusion
strategies before and alongside the use of willingness strategies facilitate acceptance of
difficult experiences. For example, a client who feels ashamed by her past actions toward
her friend may concurrently think these actions—and indeed, the intense shame she feels
—means she is a bad person who doesn’t deserve this friendship and cannot face this
friend again. Belief in these thoughts will likely both enhance the experience of shame,
and prohibit the client from re-engaging with this person (assuming the client values a
continued close friendship with this person). In such a case, defusion strategies would be
used to ‘break up’ the client’s literal belief in these thoughts, helping her notice these
thoughts simply as thoughts, and willingly experience shame and other emotions that
arise in the process of re-engaging with her friend. While defusion is theoretically
thought to lessen the intensity of aversive experiences somewhat, you should not
communicate this message to the client. Doing so may implicitly encourage the client to
use defusion strategies as experiential avoidance strategies, eventually resulting in the
same problematic consequences as other EA strategies. Instead, you can describe
defusion strategies as ways of ‘unhooking from your mind’ (or something similar), with a
purpose of helping the client ‘sit with’ tough emotions and move toward what is most
important to them.

Providing the client with an initial exposure to the concept of willingness in the previous
session may likely result in the client suspecting that willingness is easier said than done.
These defusion sessions are sequenced to help make willingness a more feasible option,
before moving on to additional willingness sessions. Metaphorically, what we are asking
clients to do when we ask them to ‘accept’ extremely unpleasant emotions & experiences
is akin to asking them to stand in the middle of thorned rose bushes. When problematic
thoughts about what these experiences mean are literally believed, the thorns are real and
can cut deep. Defusion strategies temporarily remove the thorns so that the client can
remain and pluck whatever rose they happen to be after at the moment. The bushes are
often still more than unpleasant to stand in, but not deadly. Incidentally, this is not a
metaphor you should typically use with your clients, as it may lead them to think that
using defusion and acceptance strategies will make them ‘feel better’—and as a result,
may prompt them to use defusion and acceptance as EA strategies.

Defusion exercises to be used in this module include:

 Exercise: Milk, milk, milk, and one other thought (p. 41): Language is important
and effective; it can also be powerful and makes ‘monsters’ present. What
happens when we really notice what a word is? What happens to the meaning
when the context is changed?

 Saliva exercise (p. 45): Another exercise in language and words.

 Language and direct experience (p. 46): Language brings things into the room that
aren’t even there. When we say a word, is that the same thing as our direct

24
 experience, i.e., is saying the word ‘stress’ the same as feeling or experiencing
‘stress’?

 The mind is a “don’t get eaten machine” (p. 47): For survival and problem solving
in the ‘outside world’, this machine is very helpful, and we wouldn’t want it
switched off. When it comes to our ‘private experience’, this machine is not
always helpful, and now it turns on us – even though it’s doing what it’s supposed
to be doing. It becomes a problem for us when we start to buy into, and hold as
‘absolute truth’, the evaluations and thoughts that our mind tells us.

 Defusion (p. 50): involves seeing language / evaluations / thoughts simply as that,
words and thoughts, not as ‘monsters’.

 Descriptions, evaluations and rules (p. 55): Thoughts can be divided into
descriptions and evaluations. Descriptions are solid, they reflect our actual
experience. Evaluations and rules are fishy and they exist only in our ‘mind’.
Buying into evaluations can change our perception of our experience. Evaluations
can be barriers to our living a vital life, even though there is nothing solid to them.

 Mindfulness (p. 63): A defusion strategy. Mindfulness refers to a willing moment-

to-moment awareness of your experience, and adopting a non-judgmental and
gentle stance to whatever distressing or pleasant thoughts and emotions show up.
Mindfulness involves noticing our private experience and letting it be what it is
without being hooked by it.

 The Bus Driver Exercise (p. 69): An experiential exercise that is based on this
metaphor, see below (also see Audio Track 3: Mindfulness… Passengers on the
Boat).

Exercise: The Bus Driver [2]

This metaphor is useful because it can teach clients what to do with thoughts and feelings
that seem to bully them around. It also illustrates the costs of allowing thoughts and
feelings to be bullies. The client is pictured as the driver of a bus called “My Life.” Along
the road, the client picks up a number of unruly bully passengers (distressing/difficult
thoughts and feelings) that yell at the client to change course and go where they want to
go instead of where the client wants to go. The basic idea is that clients can drive and act
in a valued direction no matter what the passengers throw at them and tell them to do. It
encourages clients to let values, not their thoughts and feelings, guide them through life.

Facilitator: For this exercise you will need 4 index cards / paper on which you will write
down participant’s thoughts. You will need to choose a willing volunteer.

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 Valued Direction

Life enhancement exercises

Throughout this module, a number of different life enhancement exercises may be used,
depending on where the client is at and what their needs are. Use the following as guide
to help you determine which exercises will be appropriate for different clients.

 Ask the client to listen to Track 3: Mindfulness… Passengers on the Boat

 Have the client practice using defusion exercises with unpleasant thoughts
o E.g. “I’m having the thought ……………”
o Distinguishing between descriptions and evaluations
o Practicing a mindfulness exercise (e.g. noticing thoughts, “leaves on a
stream”)

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MODULE 3 - You are more than your pain; You
are more than your suffering; You are more
than your cancer

27
This module (1 – 2 sessions) aims to cover the following areas:

 You are not your programming

o The Observer Self

Facilitator: This section involves looking at self-evaluations and self-conceptualisations,

in other words, the kinds of thoughts we have about ourselves---our perception of
ourselves. Just like in the previous section, the goal is to help participants identify when
they are fusing with these kinds of thoughts; apply defusion techniques in relation to this;
and, to introduce to participants the ‘observer self’ and give them an opportunity to look
at these thoughts from a different perspective.

Review

Explain to the client that each session will begin with a mindfulness or ‘centring’
exercise. Explain the aims of the centring exercises (p. 5 of this manual). Then, deliver a
centring exercise. Link the mindfulness/centring exercises with the content of last week’s
and this week’s sessions. Explain how this session will further explore the processes of
the mindfulness/centring exercise.

Example centring exercises include:

 mindfulness of the breath/sounds/sensations
 mindfulness of thoughts/emotions
 mindfulness of thoughts/feelings that the client struggles with
 mindfulness of control strategies
 willingness to sit with uncomfortable thoughts/emotions

Review (see p.5 of this manual) the last session with the client as well as their life
enhancement exercise during the week. Acknowledge any effort the client has made at
engaging in the life enhancement exercises including monitoring of
thoughts/feelings/emotions/valued-living/suffering that may not have been written down.
Highlight the degree of suffering the client endorses and how hard they are trying to deal
with these tough thoughts and feelings. Further highlight the controls strategies used by
the client and identify the cost of theses control strategies. Acknowledge any valued-
living moves and highlight the client’s ability to do what is important to them in spite of
unpleasant thoughts and feelings.

Use the following discussion points, exercises and metaphors:

 The chess board metaphor (p. 77): We can often invest a lot of energy into the
battle that goes on, i.e., wanting the pleasant thoughts and feelings to defeat the

28
 distressing and unpleasant thoughts and feelings. How effective has that been for
you? What if we’re the board and we hold all these pieces? We are still the same
person, unchanged. The pieces don’t define us they are part of us. We can carry all
our thoughts and feelings and still choose to move towards our values, regardless
of what’s happening on the board?

 The Observer self (p. 79): The observer self can be likened to the chess board, or
a container that holds all the pieces.

 The Observer Self (Audio recording): “We are going to do an exercise now that is
a way to begin to try to experience that place where you are not your
programming. There is no way anyone can fail at the exercise; we’re just going to
be looking at whatever you are feeling or thinking so whatever comes up is just
right. The exercise involves listening to a recording for the next 15 minutes or so.
Close your eyes get settled into your chair and follow to the voice. If you find
yourself wandering, just gently come back and listen to the recording”.

 The sky metaphor (p. 81): The observer can be likened to the sky. The sky holds
the clouds etc. The sky does not go away or vanish when it’s cloudy.

 Two computers (p. 83): From the observer perspective we are not fused with our
thoughts / evaluations…we notice that they are there, we don’t like them, and we
don’t engage in a struggle with them, or buy them as if they ‘truly’ define us.

 Self-concept releasing exercise (see supplement): Involves relinquishing

attachment to notions of yourself. Releasing means that we will see these
statements as statements, not as literal descriptions of realities, one way or the
other (link to the Descriptions, evaluations exercise).

29
MODULE 4 - Moving toward a vital, meaningful
life---with your pain.

30
Facilitator: This section is designed to help participants choose and commit to their
personally meaningful values and goals. These values become the participant’s compass
through life. They help them to direct their course for their life.

In this section the facilitator should aim to cover:

 What are values? (p. 89): Your values involve ways of living life that give your
life meaning, vitality, and purpose. You choose your values and they act as guides.

 Values and pain (p. 91): Living your values can be painful, especially when you
experience distressing thoughts and feelings associated with not being able to
move towards your values.

 Values and feelings (p. 91): Your mind may tell you that you need to feel a certain
way in order to live your values, yet notice how many times in your experience
have you felt like you couldn’t do something and did it anyway.

 Values and action (p. 91): Values are actions. Our behaviour is the marker that
informs us about our values and the way in which we’re moving towards our
chosen values.

 Values and outcomes (p. 92; 96): We can’t control the outcome of life, yet we can
always choose our values. We can choose to live the same value even though
sometimes it is distressing, and hard. Values are about the process and not always
the outcome.

 Values and reasons (p. 95): Values are simply chosen, we don’t have to justify
them. If no-one else knew you had your values, would it matter?

 One year from now exercise - straight into written exposure (p. 99)

 Values and goals (p. 115): Goals act as waymarkers, things that we can ‘tick off’ a
list. Setting goals that move you closer toward what you value is a good way of
helping you ‘stay on track’ and live a vital, meaningful life—even when things get
confusing, disturbing, and so on.

 Values and barriers (p. 117): Barriers are internal (thoughts / feelings) and
external things that get in the way of us always living our values. Identify actions
that you can do which help you to successfully move through barriers to living
your values.

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 Values and commitment (p. 120) - There will be failures in commitment. We don’t
always live up to our commitments from day to day. We don’t always achieve our
outcomes. Commitment really is not about avoiding failure or achieving
outcomes. The fundamental question is this: Are you willing to commit knowing
that your mind will be blabbing at you, criticising you, predicting failure etc. Are
you willing to take a stand right now in your life, knowing that you will probably
screw up sometimes? The commitment is that if you do mess up, that what you
will do is pick up and take a direction that you value again.

 Provide participants with willingness and commitment worksheet (p. 125)

 Use a mindfulness exercise to get the client in touch with their values and the life
they want to lead (see Audio CD – Values: Commitment to values in spite of pain,
The Party: What do I Want my Life to Be About).

32
 Metaphors

Initial contact with the client

Roller Coaster (Hayes et al., 1998)

My experience is that this therapy can put you on a bit of a roller coaster. All kinds of
different emotions might emerge: interest, boredom, anxiety, sadness, clarity, confusion,
and so on.

Cleaning Mud from a Glass (Hayes et al., 1998)

Your emotional experience during this therapy can be a bit like cleaning out a dirty glass
with sludge in the bottom: the only way to do it is to stir up the dirt.

Session 1

Man in the Hole (Hayes et al., 1999)

The situation you are in seems to be a bit like this. Imagine that you’re placed in a field,
wearing a blindfold, and you’re given a little tool bag to carry. You’re told that your job
is to run around this field, blindfolded. That is how you are supposed to live life. And so
you do what you are told. Now, unbeknownst to you, in this field there are a number of
widely spaced, fairly deep holes. You don’t know that at first – you’re naive. So you start
running around and sooner or later you fall into a large hole. You feel around, and sure
enough, you can’t climb out and there are no escape routes you can find. Probably what
you would do in such a predicament is take the tool bag you were given and see what is
in there; maybe there is something you can use to get out of the hole. Now suppose that
the only tool in the bag is a shovel. So you dutifully start digging, but pretty soon you
notice that you’re not out of the hole. So you try digging faster and faster. But you’re still
in the hole. So you try big shovelfuls, or little ones, or throwing the dirt far away or not.
But you are still in the hole. All this effort and all this work, and oddly enough the hole
has just gotten bigger and bigger and bigger. Isn’t that your experience? So you come to
me thinking, “Maybe she has a really huge shovel – a super gold-plated steam shovel.”

33
Well, I don’t. And even if I did I wouldn’t give it to you, because digging is not a way out
of the hole. Digging is what makes holes. So maybe the whole agenda is hopeless…you
can’t dig your way out; that just digs you in.

Session 2

Feeding the Tiger (Hayes et al., 1999)

You have been dealing with your difficult feelings and thoughts [name specific ones the
client struggles with] the way someone might who lives with a very hungry baby tiger.
Although the tiger is just a baby, he is scary enough and you think he might bite you. So
you go to the fridge to get some meat for him so he doesn’t eat you. And, sure enough,
throwing him some meat shuts him up for a while. But he also grows just a little bigger.
So the next time he’s hungry, he’s just a little bigger and a little scarier, or so it seems. So
you go to the fridge to throw him more meat. Again, you feed him to keep him at bay. But
the more you feed him, the bigger he gets, and the more frightened you feel. Now
eventually that little tiger is a big tiger, and he is scarier than ever before. So you keep on
going back to the fridge to get more meat, feeding and feeding him, and hoping that one
day he will just leave you alone. Yet the tiger doesn’t leave – he just gets louder and more
scary and hungry. And one day you walk to the fridge, open the door, and the fridge is
empty. At this point, there is nothing left to feed to the tiger … nothing except …YOU.

We’ve all got pain tigers out there that look as though they could swallow us whole.
When the “physical-and-emotional-pain tigers” show up, you keep hoping that if you
feed them they will go away. You keep hoping that if you trade in jus a little more of your
life, eventually the pain tiger will leave you alone. But has this happened? What does
your experience tell you? It’s like everything in your MIND tells you that this should
work – “feed the tiger and he’ll leave you alone.” But what does your EXPERIENCE
tell you? How well does this work? Your experience is saying, “Do this and he’s quiet for
a little while. But then he returns even bigger and scarier than before.” So in this
situation, your mind says this logical-sounding plan to control pain should work. Your
experience says it clearly doesn’t. In this situation, who are you going to believe – your
mind or your experience?

Chinese Finger Trap (Hayes et al., 1999)

The situation here is something like those “Chinese finger traps” we played as kids.
Have you ever seen one? It is a tube of woven straw about as big as your index finger.
You push both index fingers in, one into each end, and as you pull them back out, the
straw catches and tightens. The harder you pull, the smaller the tube gets and the tighter
it holds your fingers. You’d have to pull your finger out of their sockets to get them out by
pulling them once they’ve been caught. Maybe this situation is something like that.
Maybe these tubes are like life itself. There is no healthy way to out of life, and any
attempt to do so just restricts the room you have to move. With this little tube, the only
way to get some room is to push your fingers in, which makes the tube bigger. That may
be hard to do at first, because everything your mind tells you to do casts the issue in
terms of “in and out” not “tight and loose”. But your experience is telling you that if the

34
issue is “in and out”, then things will be tight. Maybe you need to come at this situation
from a whole different angle than what your mind tells you to do with you psychological
experiences.

Quicksand
This situation you are in is a bit like being stuck in quicksand. Your mind tells you to
escape, to get out. And so you try and pull yourself out of the quicksand. You struggle to
get out, all the while, sinking deeper and deeper. Your mind tells you to try harder, to be
stronger, all the while, sinking you deeper and deeper into the quicksand. But what if
what your mind is telling you, to get out of the quicksand, is the very thing that will make
you sink deeper. Look to your experience; listening to your mind by trying to get out of
the quicksand is only sinking you deeper and deeper. Maybe the only way to stop sinking
in the quicksand is to stop trying to get out, but instead, lay out flat and stop struggling to
get out.

Tug-of-War with a Monster (Hayes et a., 1999)

The situation you are in is like being in a tug-of-war with a monster. It is big, ugly, and
very strong. In between you and the monster is a pit, and so far as you can tell it is
bottomless. If you lose this tug-of-war, you will fall into this pit and will be destroyed. So
you pull and pull, but the harder you pull, the harder the monster pulls, and you edge
close and closer to the pit. The hardest thing to see is that our job here is not to win the
tug-of-war... our job is to drop the rope.

Polygraph metaphor (Hayes et al., 1999)

Suppose I had you hooked up to the best polygraph machine that’s even been built. This
is a perfect machine, the most sensitive ever made. When you are all wired up to it, there
is no way you can be aroused or anxious without the machine’s knowing it. So I tell you
that you have a very simple task here: all you have to do is stay relaxed. If you get the
least bit anxious, however, I will know it. I know you want to try hard, but I want to give
you an extra incentive, so I also have a .44 Magnum, which I will hold to your head. If
you just stay relaxed, I won’t blow your brains out, but if you get nervous (and I’ll know
it because you’re wired up to this perfect machine), I’m going to have to kill you. So just
relax!.... What do you think would happen?.... Guess what you’d get?.... The tiniest bit of
anxiety would be terrifying. You’d naturally be saying, “Oh my gosh! I’m getting
anxious! Here it comes!” BAMM! How could it work otherwise?

Session 3

The Two Scales (Blackledge, 2006; Hayes et al., 1999)

Imagine there are two scales, kind of like the volume knobs on a car stereo. You know one
scale very well because it is in plain view and has become central in your life – this is the
pain scale. The pain scale can go from 0 (no pain) to 10 (worst imaginable pain). When
you first started this program, you were probably thinking, “My pain is too high. It's way
up here [gesture by lifting hand above face]. I want to get it down here [gesture by
lowering hand at around belly level], and I want you – the therapist – to help me do this.”

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So you came into this program with your pain scale set very high. It’s no fun having this
much pain, and you’ve really been suffering.

Now, there’s another scale that most people don’t know about – it’s back here [gesture by
raising and lowering hand behind head]. This is called the willingness scale. When you
started this program, your pain scale was set very high, and your willingness scale set very
low. Does this seem to fit your experience – you’ve been experiencing a lot of pain and
haven’t been very willing or open to having this pain?

Up until now, you’ve been almost completely focused on the pain scale. And I understand
why. Most people are more concerned with the pain scale because our minds tell us that
trying hard to pull the pain scale down will somehow pay off – perhaps if we focus on this
scale, we can make the pain go away [therapist demonstrates by trying unsuccessfully to
pull down on hand in front of face]. But what does your experience tell you about how well
this has worked? Focusing all your energy on this pain scale – what does this get you?

We often put so much of our time and energy into the pain scale because our minds tell us,
“If I focus hard on the pain scale, I can make my pain go down.” Yet, I’d like to share a
little secret with you. The willingness scale is actually the more important scale because
this is the one that you can actually make a choice about. No matter how hard we try, the
pain scale does its own thing – and don’t believe a word I’m saying. Check in with your
experience. What does your experience tell you about who sets the pain scale? If you were
really in charge here, I’d simply tell you to set the pain scale really low. We’d all go home;
everything would be fine, and there’d be no reason to be here. The willingness scale works
much differently. This is the scale that you do have control over. You can choose where to
set the willingness scale.

Whenever we try to control or minimize our pain, we’re choosing to set the willingness
scale really low. The absolute worst combination is when pain is really high, and our
willingness scale is set low – which, based on what you’ve told me, is where your settings
typically are. What generally happens in a situation like this (high pain, low willingness)
is that our pain locks into place and has no where to move. Remember the Rule of
Private Experiences – when you’re not willing to have it, you’ve got it? Well, it’s kind of
like that. When willingness is high, however, it’s a different story. When you choose to set
willingness scale on high, your pain is free to move [move hand up and down in front of
face to demonstrate that pain is free to move high, low, or anywhere in between].

Not being in control over the pain switch might make you feel helpless or like a victim of
your pain because if you were in control of it, you would have set your pain at 0. If you
were in control, pain wouldn't be here. You've been trying to bring your pain down for a
long time, and it just hasn't worked. This doesn’t mean that you’re helpless or that you’re a
victim of pain; it simply means that control doesn't work here. This is, after all, the world
beneath your skin! So perhaps struggling to turn the pain knob down isn’t what’s called for
here. Your experience tells you what trying to control the pain knob gets you [provide
client-specific examples of personal costs]. My guess is that it would be more fruitful to
focus our efforts somewhere else – on the willingness scale. Who sets this one again?

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That’s right. You do. This is something you can control. It is your choice whether you set
this knob high or low. Just remember that when willingness is high, your pain is free to
move. When it’s low, pain gets locked into place, often clear up here [gesture].

Session 4

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Barriers to life enhancement exercises

Common barriers Possible response [1]

to practice

“Am I doing it Notice this showing up. More stuff of the mind. That’s fine.
right” “Am I doing it right” is welcome to show up.

Mind wandering Even people who have been practicing for years have wandering
and repetitive minds sometimes.
habits of mind
The key is not to turn the thoughts off. It is to relate differently
to the thoughts that show up.

See thoughts and feelings for what they are: streams of thinking,
passing sensations, rather than getting lost in them.

The essence of mindfulness is the willingness to begin over and

over and over again.

“I don’t have time Communicate that not doing practice will be likely to influence
to do the practice” what they get out of program, but do not be critical of them.

Ask clients curiously about what is going on. Encourage clients

to being an inquiring mind to the difficulty of finding time for
practice.

Notice any thoughts and feelings that might be blocking

homework activity.

“I get bored with Deal with this kind of feedback matter-of-factly, in an empathic
doing meditation / and accepting way, yet not surrendering the importance of
‘practice practicing as if clients’ lives depended on it.
exercises’”
You respond to the negative thoughts and feelings by being
genuinely curious and accepting them….this provides an
example to the client of a very new stance toward negative
emotions and feelings….one of curiosity rather than trying to
get rid of.

If client asks “what should I do,” don’t rush into problem solve

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 with your ideas of a “best method.” Ask what they have already
done, and did it work. (Don’t want to encourage the idea that if
they just find the right shovel, they will be able to dig
themselves out).

“I enjoy the The program isn’t exactly about feeling relaxed, another
mindfulness potential control move, but we don’t want to criticise them for
exercises cause this.
they help me to
relax / fall asleep” “Ok, this is interesting isn’t it? And obviously we hope that this
will eventually become a way of “falling awake,” of learning
“It didn’t do how to relax into awareness”
anything for me, I
just fell asleep” Sometimes, when we just accept things and let them be, we will
just settle down into a sort of peaceful, gathered, relaxed state,
or we may not. But the one thing to remember is that this is not
the goal or expectation. We are not practicing mindfulness with
the intention of being relaxed by the end and checking to see if
we are getting there are not. If we aren’t tense throughout the
whole thing and can bring our attention to the present moment,
than that’s it.

“I’ve tried to do Goal is being. Dropping into the moment. Settling into each
this before and I moment.
try my best, but I
still don’t think I Practice involves letting go of impulse to fix or changing. To
get it, I think I escape or make better, or to be somewhere else in this moment.
need to work
harder at it.” Mindfulness practice will increase freedom, expand awareness;
help you to experience life’s richness.

But the paradox is: Mindfulness ideally is practiced without any

attachment to particular goals in the moment. Progress is
possible, but only by releasing attachment to progress.

“It will upset me Avoiding is a fairly reasonable strategy, but discuss how it has in
too much” their experience worked.

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 Useful references

Blackledge J. T. (2006). Acceptance and commitment cherapy with multi-problem

teenagers.

Dahl, J. C., Wilson, K. G., Luciano, C., & Hayes, S. C. (2005). Acceptance and
commitment therapy for chronic pain. Reno, NV: Context Press.

Eifert, G. H., & Forsyth J. P. (2005). Acceptance and commitment therapy for anxiety
disorders: A practitioner’s treatment guide to using mindfulness, acceptance, and
values-based behaviour change strategies. CA: New Harbinger.

Greco, L. (?) Acceptance and commitment therapy for teens program.

Hayes, S. C., & Smith, S. (2005). Get out of your mind and into your life: The new
acceptance and commitment therapy. Oakland, CA: New Harbinger.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment
therapy: An experiential approach to behavior change. NY: Guilford.

Hayes, S. C., Wilson, K. G., Gifford, E., & Batten, S. (1998). Acceptance and
commitment therapy for the treatment of polysubstance-abusing methadone clients:
Individual therapy protocol.

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive

therapy for depression: A new approach to preventing relapse. NY: Guildord.

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