[BOOK] Kelly G. Wilson - Mindfulness for Two_ an Acceptance and Commitment Therapy Approach to Mindfulness in Psychotherapy (2009)

Kelly Wilson does a masterful job of framing the many different ways in which a therapist grounded in mindfulness might skillfully nurture greater awareness and self-knowing in his or her clients. His approach is a very creative use of mindfulness within the dyadic relationship, both verbal and non-verbal. Of course, it is impossible to engage in authentically without continually listening deeply to and learning from the myriad “dyadic relationships” we have within ourselves, as he so aptly and honestly recounts. This book makes a seminal contribution to the growing literature on ACT and its interface with mindfulness theory and practice. —Jon Kabat-Zinn, author of Full Catastrophe Living and Letting Everything Become Your Teacher and coauthor of The Mindful Way Through Depression This is a book of enormous breadth and depth, a book full of wisdom from an internationally acclaimed clinician and researcher. Wilson builds bridges between therapy traditions in a wonderful way.€For those who already teach mindfulness as part of their therapy, this is a must-read.€For those who are yet to do so, this book is the best invitation possible.€ —Mark Williams, professor of clinical psychology at the University of Oxford and coauthor of The Mindful Way Through Depression Wilson and DuFrene have provided therapists with the clearest understanding of ACT and mindfulness that I have encountered. They explain the basic theory of emotions and human learning in simple, clear, and understandable prose. Also, I found this book rich in philosophical insights concerning the human condition. Their models of assessment and intervention flow from this basic knowledge and philosophy. This work will help all therapists see a new way to understand and assess their clients’ suffering and potential for improving their lives. They will also learn to construction treatment plans to make such a transition. —Raymond DiGiuseppe, Ph.D., ABPP, professor and chair of the Department of Psychology at St. John’s University This book provides the clearest description I’ve seen of how understanding both mindfulness and behavior analysis contributes to effective therapy. It also provides unique, creative, and powerful exercises to help therapists cultivate mindful awareness of their interactions with their clients to create life-changing conversations. —Ruth A. Baer, professor of psychology at the University of Kentucky

In this book Wilson, an internationally respected therapist, provides an outstanding and innovative overview of new trends in behavior therapy and mindfulness and shares his insights into the complexities of what happens when we try to use our own mind to heal the minds of others. Beautifully written, clear and bristling with wisdoms from a very experienced therapist, this gem of a book will be a pleasure to read and a source for much reflection and learning. —Paul Gilbert, author of Overcoming Depression and The Compassionate Mind There is tremendous change occurring in our collective thinking regarding empirically supported interventions. Mindfulness for Two portends the direction of this change, where the scientist, therapist and client are motivated and affected by the same set of principles. Mindfulness in general and ACT in particular apply to both the client and the therapist, and Wilson and DuFrene are insightful, emotionally honest, and pragmatic. This is a refreshing and timely contribution to therapy process. —Thomas J. Dishion, Ph.D., director of the Child and Family Center and professor of psychology and school psychology at the University of Oregon This is an extraordinary book. Wilson speaks to the reader directly and honestly. He uses not only state-of-the-art scientific research but also his own most intimate personal experiences, his considerable clinical wisdom, and even great poetry to explain some of the most technical concepts in modern behavior analysis. The book avoids getting bogged down in detailed theoretical analysis of questionable relevance to clinical work. Of equal importance, it avoids the kind of unprincipled, superficial technology common to many clinical guidebooks. Wilson demonstrates how the ancient concept of mindfulness, when understood within the context of modern behavior analysis and the new behavior therapy known as acceptance and commitment therapy, provides fresh insights into the psychotherapy process. Mindfulness for Two is a must-read for both novice clinicians seeking an introductory treatment of modern behavior analytic psychotherapy and for seasoned clinicians who wish to deepen their understanding and skills. —James D. Herbert, Ph.D., professor of psychology and associate dean of the College of Arts and Sciences at Drexel University

mindfulness for two An Acceptance and Commitment Therapy Approach to Mindfulness in Psychotherapy

KELLY G. WILSON, PH.D. WITH TROY DUFRENE

New Harbinger Publications, Inc.

Publisher’s Note This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering psychological, financial, legal, or other professional services. If expert assistance or counseling is needed, the services of a competent professional should be sought. Distributed in Canada by Raincoast Books Copyright © 2008 by Kelly G. Wilson and Troy DuFrene New Harbinger Publications, Inc. 5674 Shattuck Avenue Oakland, CA 94609 www.newharbinger.com All Rights Reserved Acquired by Catharine Sutker; Cover by Amy Shoup; Text design by Tracy Marie Carlson; Edited by Jean Blomquist “Kindness” is reprinted by permission of the author, Naomi

Shahib Nye, from WORDS UNDER THE WORDS, Far Corner Books/Eighth Mountain Press (1995). Excerpts from “Burnt Norton” in FOUR QUARTETS by T.S. Eliot, copyright 1936 by Harcourt, Inc. and renewed 1964 by T.S. Eliot, reprinted by permission of Houghton Mifflin Harcourt Publishing Company. Excerpt from DEATH OF A SALESMAN by Arthur Miller, copyright 1949, renewed (c) 1977 by Arthur Miller. Used by permission of Viking Penguin, a division of Penguin Group (USA) Inc. “What We Knew,” by Carolyn Elkins, from Daedalus Rising, Emrys Press, 2002, reprinted by permission of the author. PDF ISBN: 978-1-60882-576-9 The Library of Congress has cataloged the hard cover edition as: Wilson, Kelly G. Mindfulness for two : an acceptance and commitment therapy approach to mindfulness in psychotherapy / Kelly G. Wilson, with Troy DuFrene. p. ; cm. Includes bibliographical references. ISBN-13: 978-1-57224-631-7 (hardcover : alk. paper) ISBN-10: 1-57224-631-6 (hardcover : alk. paper) 1. Mindfulness-based cognitive therapy. I. DuFrene, Troy, 1972- II. Title. [DNLM: 1. Cognitive Therapy--methods. 2. Attention. 3. Meditation. 4. PhysicianPatient Relations. WM 425.5.C6 W749m 2009] RC489.M55W55 2009 616.89’1425--dc22 2008052207

To Mississippi, a persistent teacher of the fine art of slowing down.—KGW To the moment (well, one in particular: 28 April 2008, sometime between 20:30 and 23:00 MDT)—TD

The hardcover edition of this book came with a bound-in DVD-ROM that contained copies of the worksheets you’ll find in Mindfulness for Two, guided meditations in MP3 audio, and QuickTime video files that demonstrated some of the clinical interventions described in the book. All these files are available to you as a free download at: 22669.nhpubs.com

Contents

A Letter from the Series Editor. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . vii Acknowledgments. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . ix Prolegomenon Finding My Way to Mindfulness for Two . . . . . . . . . . . . . . . . . .å°“ . . . . . xi Chapter 1 Coming Face-to-Face with the Human Condition. . . . . . . . . . . . . . . . 1 Chapter 2 A Clinician’s Guide to Stimulus Control. . . . . . . . . . . . . . . . . . . . . . . 23 with Emily Sandoz, MS, and Kate Kellum, Ph.D. Chapter 3 The Hexaflex Model and Mindfulness from an ACT Perspective. . . 45 Chapter 4 Integrating Mindfulness Work into ACT. . . . . . . . . . . . . . . . . .å°“ . . . . 77 Chapter 5 Clients and the Present Moment. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . 97 Chapter 6 Therapists and the Present Moment. . . . . . . . . . . . . . . . . .å°“ . . . . . . . 125

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Chapter 7 Experiential Case Conceptualization . . . . . . . . . . . . . . . . . .å°“ . . . . . . . 149 with Emily Sandoz, MS Chapter 8 Making Experiential Contact with Mindfulness. . . . . . . . . . . . . . . . 197 Epilogue Slowing Down. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . 225 Appendix A Using the Mindfulness for Two DVD-ROM. . . . . . . . . . . . . . . . . .å°“ . . 229 Appendix B The Valued Living Questionnaire (Version 1) . . . . . . . . . . . . . . . . . .å°“ 231 Recommended Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 References. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . 239

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Dear reader, Welcome to New Harbinger Publications. New Harbinger is dedicated to publishing books based on acceptance and commitment therapy (ACT) and its application to specific areas. New Harbinger has a long-standing reputation as a publisher of quality, well-researched books for general and professional audiences. The therapeutic relationship is the base of psychotherapy. Functional analysis is the base of traditional behavior therapy and behavior analysis. Mindfulness, acceptance, and values are increasingly forming the base of modern cognitive and behavioral methods. Mindfulness for Two is the first book to bring these strands together in a way that empowers and transforms them all. It is a groundbreaking volume that will leave few readers unchanged. Whether new to ACT or experienced ACT therapists, readers will find themselves drawn to a cusp and asked to pause there—not because they are being abandoned, but because they are being asked to experience what is possible when the question is as important as the answer. Mindfulness for Two carefully defines mindfulness from an ACT perspective and shows how it applies to the moment-to-moment interactions between therapist and client. It develops an approach to diagnosis and case conceptualization that€requires the clinician to slow down and mindfully attend to what is present. The functional conceptualization that this process yields is tightly linked to treatment and to what we are learning in behavioral science. Each ACT process is used to help cast a new light on the situation faced by clients and clinicians. The book challenges therapists to give up comfortable linearity and instead do their work inside a flexible space where every ACT process is available and potentially relevant to every therapy moment. Kelly Wilson, Ph.D., is a leading developer, trainer, researcher, and thinker in contextual behavioral science in general and ACT in particular. Mindfulness for Two speaks with Kelly’s voice, amplified by his cowriter Troy DuFrene. That voice, like Kelly himself, is passionate, caring, and insightful. An author of the original ACT volume (Hayes, Strosahl, & Wilson, 1999), Kelly has trained thousands, and his training experiences show in these pages. The book teaches. Details are given and insights shared. The combination of head, hand, and heart that is ACT exudes from every page. As part of New Harbinger’s commitment to publishing books based on sound, scientific, clinical research, we oversee all prospective books for the Acceptance and Commitment Therapy Series. Serving as ACT series editors, we comment on proposals and offer guidance as needed, and use

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a gentle hand in making suggestions regarding the content, depth, and scope of each book. Books in the Acceptance and Commitment Therapy Series:

• Have an adequate database, appropriate to the strength of the claims being made.

• Are

theoretically coherent. They will fit with the ACT model and underlying behavioral principles as they have evolved at the time of writing.

• Orient the reader toward unresolved empirical issues. • Do not overlap needlessly with existing volumes. • Avoid jargon and unnecessary entanglement with proprietary methods, leaving ACT work open and available.

• Keep the focus always on what is good for the reader. • Support the further development of the field. • Provide information in a way that is of practical use readers.

to

These guidelines reflect the values of the broader ACT community. You’ll see all of them packed into this book. Kelly worries periodically that his colleagues will demand more citations and text that’s denser empirically. Possibly, but those who know the literature know that this book is on firm empirical ground, and when it reaches into the unknown it does so in a way that plausibly extends what evidence suggests. This series is meant to offer professionals information that can truly be helpful, and to further our ability to alleviate human suffering by inviting creative practitioners into the process of developing, applying, and refining a better approach. This book provides another such invitation. Sincerely, Steven C. Hayes, Ph.D., Georg H. Eifert, Ph.D., and John Forsyth, Ph.D.

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Acknowledgments

Writing this book has been part of an ongoing process for me. In 1985, I began a journey out of an incredibly dark place. All along the way there have been people who have nurtured me—people who saw something in me that I couldn’t see in myself. I would like to acknowledge my teachers, especially Steve Hayes, Linda Hayes Parrot, Sam Leigland, Richard Baldasty, Dexter Amend, Bill Follette, Victoria Follette, and Lois Parker. These and many others brought me to this day. Sometimes I tell people that my current job is to travel around the world falling in love with people—a pretty good gig if you can get it. Back in 1985, I could not have imagined finding myself in the world I now inhabit. I want to acknowledge New Harbinger. The NH folks have been terrific and supportive. I especially want to thank Matt McKay. Matt, with tears in his eyes, asked me for this book at the Association for Contextual Behavioral Science Summer Institute in 2007. Matt said that I didn’t have to write a word, that I could just talk into a recorder and send it off to New Harbinger. Of course, this book was not written that way, but what Matt said seemed to free me up to write in my own voice. Thanks also to Catharine Sutker for pursuing me for the past half dozen years and for introducing me to Troy DuFrene. I feel that I have made a friend for life in Troy—a true brother. On the mindfulness front, I extend the warmest thanks to Jon KabatZinn for his kindness and support. Jon’s guidance in planning my sabbatical and the lovely week with him and Saki Santorelli at Mt. Madonna in California were priceless. I would like to acknowledge John McNeil for his kind assistance in helping me talk and think about the relationship

Mindfulness for Two

between my work and Eastern philosophical and practice traditions. And I offer many thanks to Mark Williams for his gentle openness over the years and to Barry Silverstein for pushing me to think harder about the ACT-mindfulness connection. The video segments associated with the book wouldn’t have been possible without the heroic assistance of Ragnar Storaasli and his students and colleagues in Denver. My warmest thanks go out to Ragnar and to Cari Cornish, Lisa Michelle Fuchs, Matt Heermann, Katherine Holt, Bennett Leslie, Ellen Lewis, Emily Sandoz, Joanne Steinwachs, and Brandon Ward. I’m also very grateful to Jay Wren and the kind people at Agren Blando Court Reporting & Video, Inc., for their camera and audio work. I must acknowledge my most faithful lab codirector Kate Kellum and the grad students in my lab and supervision group at Ole Miss who have let me try ideas out on them over the years. Thank you to Amy Murrell, Laura Ely, Miguel Roberts, Sushma Roberts, Lisa Coyne, Rhonda Merwin, Catherine Adams, Jonathan Weinstein, Chad Drake, Jenny Kitchens, Leslie Rogers, Stephanie Nassar, Emily Sandoz, Regan Slater, Scott Bethay, Nadia Lucas, and my most recent find, Lindsay Martin. Lastly, I want to thank my wife Dianna and my daughters Sarah, Emma, and Chelsea for loaning me out to the world on a very frequent basis over the past ten years. None of this would mean much without you. “Set me as a seal upon thine heart, as a seal upon thine arm: for love is strong as death.”

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Prolegomenon

Finding My Way to Mindfulness for Two

In June 2006, I found myself presenting a workshop at the International Mindfulness Conference in Bangor, Wales. The invitation surprised me. I’d thought some about the relationship between the work I do and mindfulness before that conference, though not really a great deal. At the conference, I prepared the audience to do an exercise called the Sweet Spot. The exercise, described later in this book, is a meditation for two on a sweet moment in life. As I began putting the audience together in pairs for the exercise, I noticed a gentleman at the back of the room. He had come in a little late that morning. I went to the back of the room and invited him to join the exercise. He declined, saying that he’d just flown into the UK and was feeling a bit jet-lagged. In the end, we had an odd number of participants without him. He was a good sport and agreed to join us. We did the exercise, debriefed a bit, and then went to get something to eat. At lunch, this fellow who’d been sitting in the back of the room came up to me, reached out and shook my hand, and said, “Hello, my name is Jon Kabat-Zinn.” What can I say? I didn’t recognize him from his book covers. Later that day, during the coffee break, I confided in Jon that people sometimes asked me if I had a mindfulness practice. I told him that I never knew exactly how to answer. I told him that I didn’t sit on a cushion for forty-five minutes each morning.

Mindfulness for Two

“But,” I said, “I do this,” referring to the meditation for two we had been doing on the sweet spot and to similar work with clients. “So, what do you think?” I asked Jon. “Is this a mindfulness practice?” “If this isn’t mindfulness, I don’t know what is,” Jon replied. This vote of confidence from a man who has done so much to promote the concept of mindfulness means a lot to me, and it gives me some comfort when I describe the contents of this book as a part of a mindfulness practice. The aim of this book is to get you acquainted with something I call mindfulness for two. This is, in short, a collection of attitudes, sensitivities, and practices, the goal of which is to increase conscious attention to the present moment on the part of both the therapist and the client in a psychotherapeutic situation. Mindfulness for two, at least as I’m going to talk about it in this book, is inseparable from the larger body of work called acceptance and commitment therapy (ACT), a branch of cognitive behavioral therapy that integrates mindfulness and acceptance strategies with values-based committed action as a means to increase psychological flexibility. Mindfulness for two is also resonant with the many traditions of mindfulness, although it isn’t necessarily of any one of them, having goals that are unique to the psychotherapeutic relationship as it is developed in ACT. Many of the leaders of the application of mindfulness to health care today began with an interest in mindfulness born of personal experience. Folks such as Jon Kabat-Zinn, Marsha Linehan, and Alan Marlatt had meditation practices of different sorts for many years. They saw benefits from their personal practices and sought ways to bring these benefits to their clients, adapting meditation practices for individuals who suffered from various physical and psychological difficulties. This wasn’t my path. My own path to teaching mindfulness didn’t emerge from the translation of a formal mindfulness practice into an application for use in health care. I didn’t come to mindfulness out of my strength in mindfulness. I didn’t come to mindfulness out of any strength at all. I came to mindfulness out of a weakness: my own mindfulness practice with clients came from my complete inability to listen to them carefully. It’s really remarkable how well a person can get by without listening. Most conversations don’t require a great deal of attention. We can drop in and out of them, nodding occasionally. Even if we lose our place, we can readily catch up. As with driving, if we’re well practiced, we can engage in a conversation almost automatically, with very little attention. Perhaps you’ve had the experience while driving of suddenly becoming xii

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aware that you’ve driven a dozen miles without the slightest idea of what you passed or what you had been doing while behind the wheel. When this sort of thing happens, you snap to attention, but unless you’ve driven off the road, there are no particularly serious consequences. When you have a similar experience while engaged with a client, though, the stakes are a lot higher. I recall with incredible clarity sessions in which I would suddenly find myself sitting in front of a client who was pouring her heart out while I had no idea what she was talking about. This is very embarrassing to admit, yet it is very true. Needless to say, this problem with attention was a real deficit for me as a therapist, as someone for whom careful listening is a core skill. The truth for me, though, is that I have a busy mind. I’ve always been that way; as a young student, half of my attention was on my teachers in school and the other was out the window, watching the clouds, thinking about what would happen later and what had happened before. It isn’t surprising that I carried this tendency over into the therapy room. I was a skillful enough conversationalist to keep clients from noticing my lapses in attention, but I recognized that the lapses were occurring. And I felt bad. Unlike the driving example, there were consequences. My clients were only being half heard—or, worse, not heard at all. I’ve had a long, unsuccessful history of privately promising myself to mend various of my ways. I’ve found that it’s typically more fruitful for me to confess my misdeeds publicly and then set things right according to what it is that I value. That’s what I began doing with clients. I would say something like “I’m sorry, but I’ve missed some of what you were saying, and it’s important that I really hear you. So, if you would, let’s back up just a bit. I’d like you to say again what you just said, and let me listen. Let me listen until I hear the heart of what you are saying.” I recall a client I saw in therapy in the early 1990s as the first instance in which I can clearly see seeds of my current practices. I was treating a young woman, an artist. She was very bright and funny and odd and troubled. Although she was otherwise quite articulate, she had very little insight into her own emotional life. As I sat and listened to her, I would occasionally see the smallest transient glimmer, a tiny hint of emotion that would evaporate like a single raindrop on a hot summer sidewalk. I would ask, “What was that?” She would reply she had no idea at all what I was talking about. She liked and respected me though and was willing, when I asked her, to back up in the story and tell the part again that had stirred the bit of emotion. It often took several attempts. She would come upon the bit of difficult material. I would see that transient shift in her affect. Then xiii

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her pace of speech would quickly speed up, and we’d be on to a new topic. We often had to back up and slow our pace down many times in the course of a session. Eventually we learned to stop and linger at these cusps, these small transitions. And in these margins we found a lovely richness. We found much pain, which speeding along held at bay. But we also found—mixed with those tears—laughter, love, and compassion. She learned to stop on her own, outside sessions, and linger at those interstices. She drew on this new experience to produce a series of paintings, which she displayed in a show called “Stopping.” I still have a poster from the show. And I still remember those moments we spent together, learning to stop. Since that therapy experience, there have been grants, new academic and research posts, many new students, and dozens of workshops, all of which seem, in retrospect, to have led me inexorably from a complete inability to listen well to the mission of teaching mindfulness for two, a different sort of listening and speaking. In writing about and conducting trainings using this material, I’ve found myself filled with questions. What if we took that focused yet flexible, open, and accepting attention that we cultivate on the meditation cushion into our interactions with clients, trainees, and peers? How would those conversations be transformed? How would they differ from more ordinary conversations? The adoption of a formal mindfulness practice isn’t part of ACT, although it’s in no way inconsistent with ACT. This book describes the use of mindfulness processes in our interactions with clients; it’s much less concerned with formal mindfulness practice. Since it’s not in my field of expertise, I’m happy to leave the teaching of practices such as sitting meditation to those better qualified. What I am expert in is behavior analysis and its application to psychological difficulties. The rise of mindfulness-oriented work in recent years has spurred me to think more carefully about the role of mindfulness processes in ACT. Although the seeds of it were there from the start, it’s only recently that I feel I have begun to grasp how integral mindfulness processes are to other therapeutic processes in ACT. In his lovely book On Becoming a Person, Carl Rogers says, “What is most personal, is most general” (1995, 26). I’ve bet my career that Carl Rogers is right. This book is personal. It’s personal for me, and I hope you’ll allow it to be personal for you. I realize there’s some risk in writing predominantly to you, the reader, directly. You may find it intrusive that I speak directly to you. If that’s so, please forgive me. Many if not most psychology texts are written to a remote third person; I realize you’ll be xiv

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used to this more formal but perhaps less engaged voice. But when we sit down with our clients, their very presence in the room with us invites to be more present with them, to be more aware of where we are in relation to them. My hope is that, by addressing you directly, I’ll be inviting you to be more aware of where you are in relation to me, to the discussion in this book, and to your clients. Also, ACT doesn’t draw any hard lines between clients and therapists, so it seems only right that I not draw any hard lines between you and me. Many of us in the ACT-treatment-development community think that the same processes that create obstacles for clients create obstacles for therapists. We share this sensibility with fellow travelers in the mindfulness community. Further, we think that the best way that therapists can learn about ACT principles is by examining them in our own experience—a sort of self-as-laboratory perspective. Consider this foreword, then, as a sort of informed consent. If you’re offended by me speaking directly to you, or if you’re unwilling to sit with hard things, both your own and your clients’, this book isn’t for you. However, if you’ll accept my intrusion for a few pages, this book may provide experiential learning in addition to the usual didactics that fill our bookshelves. Before we go any further, let me call your attention to the DVD-ROM bound into the back of this volume. The disc contains QuickTime video that demonstrates some of the things I’ll be discussing as we go along. I’ll reference some of the content on the disc from time to time. For a more detailed description of the contents of the disc and how to take advantage of it, flip back to Appendix A. I’m grateful to all those clients who suffered through my learning curve and who helped me to find my way in that therapy room. I also owe Judith Soulsby, who engineered the invitation to Bangor in 2006, a great debt for putting me in a position that required me to think hard about ACT and mindfulness. In the days since that workshop in Bangor, the relation between the present-moment-focused ACT work I do in training and mindfulness has thoroughly occupied my thinking. People who have been to my workshops over the past couple years have been subjected to my developmental process, much like the clients who came before them. I owe all of them a debt and hope that there are things in this book that partly repay their patience with me.

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Chapter 1

Coming Face-to-Face with the Human Condition

My psychology is personal. It’s my hope that in this chapter and those that follow, I’ll make this psychology personal for you too. It’s my conviction, my working assumption, that there’s a commonality and ubiquity to human suffering and that if we’re willing to sit in kindness with our own, we’ll be able to hear the hearts of our fellows. Though important, the hearing of hearts isn’t the whole of this work. But it’s an important first step: the fostering of a place from which our clients and we can work together. Empirical clinical psychology has had a hard time seeing the unity of human suffering, though the data lie all around us. Why? I believe that the unity of human suffering is obscured by the very categories we impose upon it. This book is an argument that there is value in looking past the categories for a moment at least and in letting what we see there change us. In this as in many other matters, sometimes poets have a clearer view: Before you know what kindness really is you must lose things, feel the future dissolve in a moment like salt in a weakened broth. What you held in your hand,

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what you counted and carefully saved, all this must go so you know how desolate the landscape can be between the regions of kindness. ............... Before you know kindness as the deepest thing inside, you must know sorrow as the other deepest thing. You must wake up with sorrow. You must speak to it till your voice catches the thread of all sorrows and you see the size of the cloth. —Naomi Shahib Nye, “Kindness” (1994, 42–43) It’s my sense that, with the best of intentions, we lose sight of the size of the cloth, right there in the room with our clients, and losing sight of that cloth has a cost both to us and to them. So I invite you to come along on this next part of our journey. I’ll warn you in advance that there are some stops on this trip where the view may be both panoramic and painful.

THE GREAT FACT OF HUMAN SUFFERING Go, go, go, said the bird: human kind Cannot bear very much reality. —T. S. Eliot, “Burnt Norton” (1991, 176) And we mental health professionals, how much reality can we bear? The prevalence of particular psychiatric diagnoses can be misleading. Taken singly, diagnostic categories are relatively rare. In a sample of fifteento fifty-four-year-old Americans, we can expect only 2.8 percent to be diagnosable with drug dependence, 3.1 percent with generalized anxiety disorder, and 2.5 percent with dysthymia within a given twelve-month period (Kessler et al., 1994). There’s a certain safety in the rareness of these categories. Their uncommonness puts a bit of distance between us and suffering, between our loved ones and suffering. The categories are somewhat abstract and not personal. Setting aside the categories for a moment, however, we see a much different picture. In the same study cited above (Kessler et al. 1994), a survey of only fourteen of the categories in the Diagnostic and Statistical 2

Coming Face-to-Face with the Human Condition

Manual of Mental Disorders (DSM), report that more than 29 percent of fifteen- to fifty-four-year-olds experienced sufficient symptoms within the last twelve months to qualify for at least one Axis I psychiatric diagnosis. Among fifteen- to twenty-four-year-olds, the rate was 34 percent. Again, this was not a clinical sample or an “at risk” sample. It was a representative community sample. Even these numbers tell only a partial story about human suffering. These statistics include only fourteen of the dozens of DSM Axis I disorders. They don’t include any Axis II disorders. They also don’t include the myriad forms of compromised adjustment—the DSM V-codes. They don’t tell us how many live in marriages filled with acrimony or perhaps empty of any emotion at all. They don’t tell us whether this person finds her work meaningless or if that person cannot talk to his children. These statistics also don’t include subclinical cases. Should the person who feels depressed most of the day, nearly every day, who has lost pleasure in all or most all activities, who feels worthless and has no energy be relieved because she doesn’t have that fifth symptom and therefore doesn’t meet criteria for depression? Is there any difference in kind between the person who has four and the person who has five symptoms? In order to bring this point home more forcefully, consider these statistics as you walk through a typical day. Think about the people who work in your office or building. Let your attention move from one face to the next as you walk down the street. Count people silently as you meet them: one, two, three, one, two, three. Let yourself notice that approximately every third could be diagnosed this year if only the right set of questions were asked. Notice also that, for the most part, they look just fine. And how about you? Suicide and suicidal ideation give us another telling window into human suffering. Suicide itself is relatively rare. In the United States, there are approximately eleven deaths by suicide per 100,000. In other words, about 1/100th of a percent of the population will die by suicide (Centers for Disease Control and Prevention, n.d.). However, one study (Chiles & Strosahl 2005) found that 20 percent of a community sample reported a two-week period of serious suicidality, including the identification of a plan and the means to carry it out. They reported an additional 20 percent who had the ideation but without a specific plan. This suggests that nearly half the group was likely suffer to such an extent that they seriously considered ending their own lives as a way to end their suffering. It doesn’t strike me as reckless to imagine that this statistic could apply more broadly—much more broadly. 3

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If it does, what might this mean for you? It might mean that half of the people you know have had, or will have, a moment of such pain and despair that death seems a kinder option than soldiering on. But will they tell you? No. Not half or likely even one in a hundred will ever say a word. They’ll come to work, to class, to therapy, to the dinner table. You’ll ask them how they are. And they’ll tell you they’re fine. Suicide seems safe as an obscure statistic. It’s even pretty tolerable, if worrisome, for most mental health professionals to talk about when it strikes at work or at a local school. Yet completed suicide is rare. Even when it strikes in our town or at work, it recedes from awareness before long. But really consider the implications of nearly half the population giving serious thought to self-slaughter. Let yourself recognize whom this is about. As you move through your day, pause for just a moment as you greet each person and count silently again: one, two, one, two, one, two. Let yourself hesitate and glance a moment and look into those eyes. Let yourself wonder. Don’t do anything about it. Just pause and wonder. At the next staff meeting, cocktail party, or PTA social, let your eyes move about the room. Let it sink in that nearly half of those you’re seeing will know this dark night of the soul. And, most likely, the next day they’ll come into work, and they’ll be “fine.” Even that is too abstract. How many brothers and sisters do you have? Stop a moment and close your eyes. See their faces, and let yourself quietly say their names as you do. And count again. One, two, one, two. See if you can see, as you look into those eyes, hints of that suffering— just the other side of “fine.” Worse still—do you have children? One, two, one, two. See if you notice—right in this moment—how much you want me to stop, to move on to the next point. And, in that rejection, we find the altogether human reaction to suffering. We want to hold it distant or not at all. In that rejection, we also see the source of all that silence, we see why the automatic answer to “How are you?” is “Fine.” And how about you? Do you know that dark night? And how are you? And who knows about that? I was presenting this material recently, and a young man in the audience said somewhat angrily, “Could you stop with the gruesome personal examples?! I don’t want to think about my own children being suicidal. It would be easier to understand this if you didn’t do that.” I did fall silent. I stood speechless for a moment in front of a hundred people. And I did stop giving personal examples. But in that moment, in the front of that room, I thought hard about Eliot: “Go, go, go, said the 4

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bird: human kind cannot bear very much reality.” I suspect that the pervasiveness of human suffering isn’t any easier to understand without the personal examples, but I have no doubt it’s easier to tolerate. We so want suffering to be an abstraction, to be about someone else, somewhere else, or at least somewhen else. As an old Greek saying puts it, luck is when the arrow hits the other guy. I went silent that day, but in my hesitation, I became keenly aware of the cost of that silence. I paid a price personally. So did all of the people in the workshop. In a way, the countless people who go silent in the face of suffering every day pay a price in that moment of concession. Why is it that we, our brothers, sisters, friends, and, yes, even our own children, will surely suffer and likely suffer alone? We all bear some responsibility and possess some ability to respond. But we remain silent about our own suffering. And, in sometimes subtle and sometimes not-so-subtle ways, we conspire to silence suffering around us. When talking with clients about suffering and especially suicidality, I’ve sometimes gone for a walk with them and counted: one, two, one, two, one, two. “That one? And that one? And maybe that one.” I sometimes ask whom my clients have told. Most commonly they answer, “No one.” “Them too,” I reply, nodding toward the ones we just counted. If they admit to having told someone, I ask, “How did that go?” The most common response is near apoplexy on the part of the person in whom they confided. This is often true even of mental health professionals. Please be clear: I’m not advising my clients to go out proclaiming their suffering. This exercise of wondering how many of those we encounter each day suffer in silence is an act of appreciation, not a prescription for future action. Having to tell is as much a trap as having to remain silent. The exercise is a chance for us to sit with suffering and appreciate the size of the cloth. What would it mean for us, as professionals, if we let ourselves see that the supposed rarity of any given mental health diagnosis was a just a trick of perception? The result of looking at the whole cloth of human suffering as though it were a thousand separate threads? What would it mean if we all learned to catch “the thread of all sorrows”? If we truly apprehended the vast size of the cloth into which we, client and therapist alike, are woven? I’m suggesting another path we can take. What if our willingness to let this suffering come close allowed us to sit near our clients and to truly hear the heart of their suffering? Really it’s not even so much letting it 5

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come close as it is letting ourselves see how close it already is. Could it be that in the same ways that we conspire to silence suffering, we could begin to allow suffering to be present, for the good of our clients, ourselves, and those we love?

EXERCISE: Letting Suffering Get Close Let your mind come to rest on some of the figures listed above, especially the statistic that more or less half of us have known pain and desperation so acute and so severe that we’ve seriously considered taking our own lives. Bear this statistic in mind as you engage in this simple exercise. Before you begin, find some way to time yourself—an egg timer, a stopwatch, an alarm clock. Allow about three minutes to consider each of the following scenarios. Just sit with them; let them be. Don’t try to understand them, solve them, or sympathize with them. Just notice them; let them get close to you. When you finish with one scenario, open your eyes and take a few breaths. Then move on to the next. Be warned: Your mind will literally do backflips to get you to run away from these scenarios, more so as they progress. When it does, thank it for the effort and gently return your attention to the scenario. Sit comfortably in your chair. Close your eyes and take a few deep, slow breaths. 1. Imagine someone you know casually—a chance acquaintance, an occasional coworker, the friend of a friend— someone whose features you know but whose personal story might be less familiar to you. Picture this person sitting alone in a room, deep in sorrow. Imagine that he has just learned of the loss of someone dear. Allow your awareness to come to rest on this person’s face. Notice the details of his expression. Do you see tears? Trembling? Shallow or rapid breath? Is the hair across his brow in disarray? Keep allowing your awareness to wash over this person like water, just appreciating his sorrow and loss without doing anything with it, until your timer goes off. 2. Now imagine someone you care about—a dear friend, a sibling, your spouse or child. Imagine that this person is struggling with an overwhelming feeling and abiding in great pain. It might be a profound sense of hopelessness, 6

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extraordinary anxiety, or a blinding rage. Let your attention fall on her body, hands, and face. See the terrific suffering in her eyes. Notice how the humor, vitality, and engagement that you may be used to seeing in this person seem to have drained away. Imagine her totally alone, with no one to turn to, feeling lost and alienated. Even though your awareness is sharply focused on this person, gently let go of any urges you feel to reach out to her. Just allow yourself to be aware of her pain until your timer goes off. 3. Finally, imagine a person, perhaps a client, whom you’re concerned about, someone you feel you’d like to help but maybe can’t help fast enough or even can’t help at all. Imagine this person, sitting alone in a darkened room. Although he is in great pain, imagine that you can see a look of cold, determined resolve on his face. Allow yourself to slowly, slowly become aware that you are watching this person on the last day of his life. Nothing you can say, nothing you can do will alter the inexorable course that, set in motion years and years ago, will now proceed to its conclusion. There is nothing to be solved now, no solutions to be found, no protocols to be followed, no avenues to explore. Let yourself simply witness this person in these last hours. Notice what your attention falls on in him, and also notice what comes up in you. Do you long to reach out to him? Do you want to figure out what has happened? Do you try to turn and run? As best you’re able, remain a witness to this person, calm and present, until your timer goes off.

WHY ACKNOWLEDGE SUFFERING? I’m sometimes asked why we should spend time lingering with the ubiquity of suffering. People ask, “Isn’t it normal to act to reduce suffering?” Of course. It’s entirely normal. It’s also normal for the dog that has been hit by a car to bite the stranger who tries to rescue it from the middle of the road. But the bite doesn’t help the dog get to the veterinarian. When the source of suffering is lions and tigers and bears that might attack and eat us, withdrawal is entirely adaptive. But what are 7

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the Â�consequences of withdrawing from psychological suffering—from embarrassment, from grief, from fear? What if withdrawing from suffering entails withdrawing from the sufferer also? As clinicians, we must ask ourselves, would I be willing to sit with suffering if it allowed me to sit with my clients? I’m not suggesting that we cultivate a morbid preoccupation with suffering. I’m not even suggesting we spend a great deal of time with it. I am suggesting that, to the extent we’re intolerant of suffering, we’ll feel compelled, consciously or unconsciously, to turn away from it in our clients and ourselves. Sebastian Moore puts it this way: The rejection of our common fate Makes us strangers to each other. The election of this common fate, in love, reveals us as one body. —Sebastian Moore (1985, 94) When we turn away from suffering, we miss the other things, rich and varied, that are inextricably linked to suffering. Values and vulnerabilities are poured from the same vessel. Consider the ways you have been most deeply hurt in your own life and see if each hurt was not connected to a deeply held value. The betrayal that led to divorce wouldn’t have hurt had you not valued the trust and love of your spouse. The taunting of the kids at school wouldn’t have hurt except that you valued companions and the respect and regard of your fellows. The death of your mother wouldn’t have hurt, except for the great love you bore for her. I don’t know of a way to breathe in without being willing to breathe out. I don’t know of a way to love without being willing to feel the sting of loss. I care about you, the reader, even though we may not have met, but I don’t know how to say these words without knowing also the fear that they will seem hollow to you.

AMBIGUITY AND SUFFERING: THE BEAR AND THE BLUEBERRIES Humans don’t just suffer when things are bad. They also suffer when things might be bad. In the experimental literature on nonhumans, it is readily shown that organisms prefer environments in which painful things are predictable over environments where they are not (Abbot, 8

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1985; Badia, Harsh, & Abbot, 1979). If pressing a lever changes a rat’s environment from one in which shocks come at random times into an environment in which they occur at regular intervals, the rats will press to produce regular shocks. This is so even when the absolute number, duration, and intensity of shocks are identical. Humans are like that too. It isn’t difficult to imagine why this might be so. There are lots of ways for a species to survive. If you’re a squid, you spawn tens of thousands of babies. If five or ten thousand of your kids get eaten, survival of your genes isn’t especially threatened. But we humans aren’t so prolific. We usually have our babies one at a time or, more rarely, in twos or threes. If even one of your kids gets eaten—well, it’s likely to be the low point of your day. So for us, as for all creatures with relatively low reproductive rates, characteristics that lead to the survival of the individual organism are at a premium. Let’s look at the relationship between ambiguity and survival in our often hostile and dangerous world. Imagine you and I are two early hominids out on the savanna. We see, off on the horizon, a vague shape. “Is that a bear or a blueberry bush?” I ask. “I think it’s a blueberry bush,” you reply. A little tentatively, I say, “I don’t know. It might be a bear.” “No, I really think it is a blueberry bush.” “Well, I’m going back in the cave, just in case.” You shrug and dash off into the distance. Later, you come back to the cave, belly distended, talking endlessly about how fabulous the blueberries were. “They were the biggest, juiciest blueberries you’ve ever seen!” you cry. “I can hardly move I’m so stuffed!” That night I go to bed a little unhappy and a little hungry. Imagine that this scenario plays out several times. Each time, I express my concern that it might be a bear and go back to the cave, and each time you express your conviction that it’s a blueberry heaven, just like last time. One afternoon you go sauntering off with your blueberry basket on your arm, but you don’t come back to the cave. When you’re still not home the next morning, I get up and go over to your part of the cave, gather up your stone ax, that mammoth hide of yours I’ve always secretly coveted, and, most importantly, your mate. If you go off to eat those blueberries enough times, eventually the shape on the horizon turns out to be a bear, and that day you’re the bear’s lunch. For us, the central evolutionary imperative is that it’s better to miss lunch than to be lunch. We’re capable of missing lunch many, many 9

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times, but we can only be lunch once (and after that, perhaps dinner and breakfast, but that’s largely up to the bear). We’re the children of the children of the children (and so forth) of the ones who played it safe and went back to the cave. As we evolved for millions of years in an unforgiving world, natural selection weeded out the brazen and the brash. Our ancestors, the ones who survived and passed on the genetic material of which we are all made, were selected for their caution. They were the ones who assumed that what’s bad is bad and what’s ambiguous is bad too.

BETTING WITH YOUR LIFE! The State of the World It’s a bear.

It’s a blueberry bush.

I bet it’s a bear.

I miss being lunch (and survive).

I miss lunch (and survive).

I bet it’s a blueberry bush.

I am lunch!

I get lunch!

This means that ambiguity itself will often be experienced as aversive. Clinically, ambiguity is often a source of considerable suffering. Consider the internal dialogue of someone addicted to heroin who has made a commitment to abstinence. Will I, won’t I? Will I, won’t I? Will I, won’t I? And the truth? No one knows. The person with the addiction doesn’t have a crystal ball; she can’t see the future. There’s only one way to know for certain, only one way she can eliminate that dense ambiguity, and that’s to stick that needle in her arm. In the moment she uses, she gets a moment of relief from the ambiguity. And, altogether too often, that moment is enough. Somehow right in the middle of the relapse, or right before a relapse, stories about “next time” seem much more plausible.

EXERCISE: Sitting Inside Significant Questions We don’t have to appeal to behavior as extreme as heroin addiction to find the seeds of this reluctance to sit with ambiguity that lie within all of us. Consider the things you’d like to do in your own life. Especially 10

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consider things with fairly high stakes: should I get married or divorced, have children, change careers, or start a new business? Ponder one of these or another that feels significant to you. Try doing this while intentionally not deciding one way or the other, and without evaluating or drawing any conclusion. Rather than decide or conclude, let yourself wonder what you will do. If you notice yourself deciding or weighing the pluses and minuses, gently let go of that process and come back to the question. Repeat the question gently to yourself, listening with care to each word. If you find yourself concluding, “Well, I’m not really going to do that” or “Sure, that’s a good idea,” let yourself notice that you are drawing conclusions about an unknown future. Your conclusion may indeed be the most likely outcome, but sometimes very, very unlikely things happen. As many times as you find yourself concluding or deciding, gently come back to the question and linger. Let yourself wonder for a few minutes. Notice also how quickly you are ready to move on to the next thing on your to-do list.

This is jumping the gun a little, but there’s another exercise in this vein in chapter 6 called To Eat or Not to Eat. It serves another purpose there, but if this idea of finding and just inhabiting the edge between doing and not doing intrigues you, you can skip ahead and take a look.

LEARNING TO LOVE AMBIGUITY Most of the things in life we truly care about are very ambiguous, and if we can’t tolerate ambiguity, we are doomed to act in the service of its elimination. I’ll come back to this topic repeatedly throughout the book, as it will be central in our discussion of work with clients. Learning to love ambiguity can be very powerful. By love here, I don’t mean the feeling or state of love. I mean love as an act: to care for or relish ambiguity, to make an honored place for it at the table, to sit with it quietly and see what it has to say to you. There are things in the midst of ambiguity that can’t be seen elsewhere. The poets understand this better than psychologists, though not necessarily in a way that readily informs clinical practice. At the still point of the turning world. Neither flesh nor fleshless; 11

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Neither from nor towards; at the still point, there the dance is, But neither arrest nor movement. And do not call it fixity, Where past and future are gathered. Neither movement from nor towards, Neither ascent nor decline. Except for the point, the still point, There would be no dance, and there is only the dance. —T. S. Eliot, “Burnt Norton” (1991, 175)

THE UBIQUITY OF HUMAN PROBLEM SOLVING The complement to the ubiquity of human suffering is the ubiquity of human problem solving. Wherever you find a human, you find a problem. A simple breathing meditation provides a marvelous example of the near impossibility of separating humans from their problem solving, and it gives us a clear window through which to observe the human condition. Give a human an altogether simple task and he’ll find a problem to solve. It’s pretty much a given that if you have a pulse, you have a problem. And if you don’t, give it a minute. The human capacity for problem solving seems near limitless. Of course, we get little reprieves here and here. But if it were common or easy to let go of problem solving, there wouldn’t be a hundred meditative traditions to teach us the altogether simple skill of repeating a word or phrase, or sitting, or breathing—of taking a moment to not problem solve. Try it yourself.

EXERCISE: Solving the Problem of Solving the Problem of Solving the Problem of… You have everything you need to try this exercise. You know how to breathe. You know how to count to ten. You know how to sit. Choose a time when you have a bit of time on your hands without any pressing responsibilities. 12

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Sit down in a comfortable position. Gently close your eyes. Begin to count your breaths from one to ten, starting again when you reach ten. Then, watch the show. Okay. Here I go: one, two…ah, my back hurts a little. You adjust a little and solve the back-hurting problem. Ahh, that’s better. One, two, three…gee, my knee hurts a little. You move your knee a little bit and solve the knee-hurting problem. There we go. Much better. Now I’m ready. One, two, three, four…this is going pretty well, feels nice…Oops! Where was I? Then you solve the wandering-mind problem. And so forth. As you go, notice how effortlessly your mind moves to solve problems and even invents problems for you to solve if none readily present themselves.

THE PROBLEM WITH PROBLEMS There are very good evolutionary reasons why problem solving is so essential to our nature. If we go back to the savanna and imagine that there was variability in the propensity to problem solve, it’s hard to imagine that many early humans lost their lives because they couldn’t sit quietly and count their breaths for forty-five minutes. It’s much more likely that the problem solvers, not the breath noticers, survived. So here we sit, at the tip of an evolutionary branch with our fellows, ready to find and solve any and every problem that exists now, existed in the past, or might exist in the future. This capacity has allowed us to outstrip every species on the planet in terms of our ability to spread across the face of the earth (and even off of it). But this marvelous capacity hasn’t come without a cost. The great success of human problem solving has a dark side. The cost is that problem finding and problem solving get extended into areas where they interfere with valued living. The irony is that, even there, they appear to be in the service of valued living. The problem with problems is that when we’re in the midst of problem solving, the rest of the world disappears for us. It makes sense that problems would dominate our awareness in this way. Returning again to the savanna, imagine our early hominid lying out on the grass on a sunny day with a belly full of food. She feels the 13

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soft grass pressing into her back, looks up at the clear blue sky, smells the sweet spring day, and feels the warmth of the sun on her face. Suddenly she hears the roar of a lion. What happens to her awareness of the grass, the scents in the air, the blue of the sky, the warmth of the sun? Gone. In that instant, everything vanishes from her awareness except the lion and the best way to make it safely to a nearby hole in the rocks that is just too small to accommodate a lion. The lion and the hidey-hole are the only things that matter in that particular moment. The trouble for us humans is that things like self-doubt, anxiety about failure, and concern about acceptance—which feel every bit as threatening to us as lions, tigers, or bears—are, in fact, very different in kind from these threatening beasts. What happens if you linger with a lion? You get eaten. But what happens, though, if you linger with depression, anxiety, or self-doubt? And what happens if you linger with a client that presents these same things? You might be tempted to say, “I’d get eaten metaphorically. I’d be pulled in, and it would get worse.” But I think you’d agree that there is significant difference, in kind, between being eaten figuratively and eaten in fact. I think you can see where I’m heading. What if problem solving twenty-four hours a day, seven days a week weren’t the best way to live? What if problem solving twenty-four hours a day, seven days a week weren’t even the best way to problem solve?

ON MATH PROBLEMS AND SUNSETS For therapists, our clients often appear to us as problems to be solved. This is especially true with our most difficult clients. I frequently do consultations on difficult cases. (Funny, people never call me about their easy cases.) When consulting on difficult cases—clients who are suicidal, clients who don’t improve in spite the best efforts, clients who keep coming back to the same issue again and again and again—I often ask therapists, “Is your client a sunset or a math problem?” The usual response is a puzzled look. “I asked whether your client is a math problem or a sunset?” “Huh?” the therapist puzzles. “What’s two plus two?” The therapist stares at me. “This isn’t a trick question: What’s two plus two?” He gives in. “Four.” “Right,” I say. “And what is three times five?” 14

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“Fifteen.” “Right again. And so, what do you do with a math problem? You solve it. Or, maybe if it’s a hard math problem, you struggle for a while first. And if it’s a really, really hard problem, maybe you struggle for a while and then give up or you ask someone else to help you solve it. But what do you do with a sunset?” The therapist pauses. “You look at it?” “Right,” I reply. “And if it’s a really gorgeous sunset, perhaps you stop, rest a moment, notice the variation in color, the way it plays off the clouds. You appreciate it. Do you ever try to solve a sunset?” “No,” the therapist replies. “Okay. So when you sit in the room with this client, what’s it like to be with her? Is she more like a problem to be solved or like a sunset to be appreciated?” “Yes, now I get your point.” “Have you ever been a problem to be solved?” I ask. “Maybe in school? Maybe at home with your parents? Or with your spouse or at work? Have you ever been someone’s problem? What was that like? What’s it like to be a problem to be solved?” “Not fun,” the therapist concedes. “And how about the way your client sees herself? Is she a sunset to be appreciated or a problem to be solved?” All of this isn’t to belittle attention to problems or to diminish in any way the extraordinary problems our clients often bring to therapy. Do our clients have problems? Sure. Are our clients problems? Sure. Are they merely problems? No. It’s simply the case that the problems get our attention and tend to diminish our attention, awareness, and, perhaps most importantly, appreciation of the whole human who is sitting in front of us. There is another side to this coin. What’s it like to be appreciated?

EXERCISE: Appreciation I would ask you to think back in life to times when you were appreciated by someone. Maybe it was a parent. Maybe you had a teacher who took a special interest in you. Close your eyes a moment and see if you can visualize that person or recall what it was like to sit with her. Linger, for a moment, with what it meant to you to be noticed, seen, admired, appreciated. 15

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As we move along in the book, I’ll introduce exercises and ways of being with clients that contain a good bit of simple appreciation. Understand, though, that I’m not suggesting that appreciation alone is sufficient. But I do feel that there’s good reason to believe that appreciation is a place from which important work can be done.

LIBERATION: THE OTHER GREAT FACT OF HUMAN SUFFERING The one great fact of human suffering is that it lies all about us. We’re capable of suffering under just about any condition. In the poem “Dover Beach,” we hear the words of the newlywed listening to the waves break on the sea coast: Ah, love, let us be true To one another! for the world, which seems To lie before us like a land of dreams, So various, so beautiful, so new, Hath really neither joy, nor love, nor light, Nor certitude, nor peace, nor help for pain; And we are here as on a darkling plain. —Matthew Arnold, “Dover Beach” (1998, 78–79) We might imagine his wife abed and Matthew at the window, contemplating the darkness and futility of the world. Frustrated with his poetic melancholy, mightn’t Mrs. Arnold say, “Just come to bed, dear?” It appears to be possible for humans to suffer under any and all conditions. However, there is a complement to the extraordinary capacity of humans to suffer, and that’s our capacity for liberation. A prototypical example can be found in Victor Frankl’s landmark book Man’s Search for Meaning (2000). In the book, Frankl describes his experience in the Nazi death camps during World War II. He speaks at length about suffering in the camps, which is no surprise. However, the point upon which the entire book turns is Frankl’s description of the time he and a companion find a way to escape the camp. They gather some food and a few other supplies. The day before their planned escape, Frankl decides to make one last round with the patients in his makeshift hospital. He knows that his medical efforts are largely futile. The prisoners under his care are 16

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dying of malnutrition, dysentery, and untold other causes. He has little to offer them except comfort. Frankl describes one fellow he had been particularly keen on saving, but who was clearly dying. On Frankl’s last round, the man looks into his eyes and says, “You, too, are getting out?” Frankl writes, “I decided to take fate into my own hands for once.” He tells his friend that he will stay in the camp and care for his patients. Upon returning to sit with his patients, Frankl describes a sense of peace unlike any he had ever experienced. I would contend that Frankl was freed that day in the camp. Even though his outward circumstances were some of the cruelest fetters devised by human beings, Frankl was able to experience freedom. What this means to me in my work with clients is that no matter what circumstance they’ve suffered, no matter what hardship or loss they’ve endured, it’s possible for them to experience freedom and dignity. I hear Frankl give voice to it, and I’ve seen it with my own eyes. One great fact of human suffering is that it’s pervasive; the other great fact is that liberation is at hand. By this, I don’t mean liberation from pain. I don’t mean “and they lived happily ever after.” I mean that I assume every client who walks through my door is capable of experiencing a sense of meaning and purpose in her life—that she is capable of having a life that she could say yes to, independent of the pain it brings. I also don’t mean that this is likely. I’m not interested in probabilities as much as I’m interested in possibilities. I care less about what’s likely to happen and more about what could happen. This may appear naive. In a certain sense it is, but it’s not a naivety born of ignoring or denying what is likely. It’s naivety chosen—a sense of wonder chosen in the service of those who ask for my help. Why? Well, sometimes very, very improbable things happen. In the early 1970s, if you had asked me how apartheid would end in South Africa, I would have bet that it would end with blood running in the streets. I was wrong. My suspicion is that when Gandhi suggested that the British could be compelled to give up their colonial interest in India without force of arms by simple, passive resistance, people thought he was nuts. And they too were wrong. I had a client fifteen years ago who participated in an HIV-positive substance abuse support group. She came to me after living for more than a decade on the streets of San Francisco as a street prostitute, thief, and heroin addict. She’d lost a couple of children permanently to child protective services because she couldn’t care for them. This was about 17

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1990, so the survival prospects for AIDS were poor. Virtually everyone in the group had watched a host of friends waste away and die. We had AZT, but none of the newer, more effective antiretroviral drugs had been developed. In that very first session, I could see in her a longing for something. I could see someone who, long ago, had imagined something better for herself—some ambiguous more. That more had not appeared, but the spark of the longing survived. Humans are amazing. I was moved to respond to that longing. I told her that if she wanted, I could help her find a place in Reno where she could hunker down, learn to take care of herself, and live out her time with some comfort. The fight against AIDS was in its early days. People were terrified of the disease. Even people who knew better would stiffen a bit when they hugged someone with AIDS. The people in that group could feel it. I told her that there was another thing she could do. In a war, the first soldiers who step up out of the trenches are all killed in a hail of bullets—every single one. And in the next wave, more of the same. Certain death follows for the soldiers in the wave after that. But perhaps in the next, a soldier or two make a few steps forward, and after that, a few more soldiers make it. And, if they keep coming and coming and coming, eventually they make it across that field of fire. I told her that day, with tears in my eyes, that I wished it were not so, but that in the fight against AIDS we were seeing that very first line of soldiers step up from the trenches. They would all fall. If she wanted, she could do that. She could step from the trenches and give voice to the plight of people suffering with her illness. There was a spark in her eyes, and she picked that banner up. “Frontline soldiers,” she said. She lived for a few more years. She got clean and stayed clean. She worked in substance-abuse treatment facilities and traveled around the region talking to women in treatment at community events. She sometimes scared the hell out of people who took her around. Her language was coarser than you’d expect from a public speaker. But her message to women was one of hope and love and compassion. “You can stop. It’s okay. You don’t have to live that way anymore.” And her message to the communities was a plea to care for the ill among them. When she died, there were maybe five hundred people at her memorial. We all benefited from the love she’d brought to the world in those

18

Coming Face-to-Face with the Human Condition

five years. My clearest image of her toward the end of her life was from a meeting we both attended. She was in wasting syndrome—thin, her hair wispy, her skin gone transparent like a fine silk covering. I was there with one of my daughters, who was an infant at the time. She asked to hold the baby. I recall with such clarity the joy in her eyes as she looked down into the eyes of my child—one life ending, another beginning. I felt then and feel blessed now to have known her. She didn’t live long, she didn’t live without pain and struggle, but she lived well. She wanted her life to be significant, to make a difference, and she chose to not allow even death to be a barrier to that significance. She lives and inspires still in the stories I and others whom she touched pass on. She left behind a real and lasting legacy. If you ever have occasion to see that great, sad AIDS quilt, she lives there too and reminds us all not to give up on our fellows. What is at the heart of this story? Sometimes, sometimes, very unlikely things happen. How likely was that story? Not likely at all, yet it happened. And what’s possible from your most impossible clients?

WILSON’S WAGER Is it possible for something extraordinary, marvelous, to happen in the lives of our most troubled clients? We don’t know. But we get to bet with our actions and with the posture we take with our clients. Blaise Pascal, a mathematician and philosopher of the seventeenth century, proposed a stake known as Pascal’s wager. This gambit examines the outcomes of assuming and not assuming the existence of God using a two-by-two contingency table. I’ve always thought of this as the logician’s approach to faith. In philosophy, it is known as the argument from dominating expectations. In a nutshell, Pascal proposed that, in the absence of a way to verify the divine through reason, we still ought to live as if God existed. If there is a God, and we live our lives as if there were so, we gain infinite reward in heaven. If there isn’t, we’re none the worse for our pains. If we choose to live as if there is no God and we’re right, there’s no problem. But if we’re wrong, we suffer infinite loss. (Pascal didn’t actually describe the details of perdition, figuring that loss of infinite gain would prove his point. But you can almost smell the sulfur.)

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PASCAL’S WAGER God exists.

God doesn’t exist.

Live as if God exists.

Infinite gain

No difference

Live as if God doesn’t exist.

The loss of infinite gain

No difference

Never having been accused of excessive modesty, I thought that if Pascal can dabble in oddsmaking, why not me? So I offer Wilson’s wager. Imagine that in the columns below we have the state of the universe. Imagine that it’s at least remotely possible that for any given client, something extraordinary could happen in his life. Here I don’t mean extraordinary on my terms but rather on his, the client’s, terms. Extraordinary might look very, very different for different clients. Extraordinary might mean finding meaningful work, reconciling with a child, or, like my client above, serving her fellows. In the rows, to the left, are our assumptions. We can assume that something extraordinary could happen, or not. What follows then, is to work through the quadrants of the contingency table.

WILSON’S WAGER Something extraordinary could happen. Assume yes

Assume no

Something extraordinary could not happen.

You and your client get to You feel bad and your experience richness. client feels bad. Your client gets sold short.

You get to feel good about being right about what a hopeless case your client was.

Beginning with the upper right quadrant, imagine that, at the end of days, you can tap some omniscient power and learn with certainty that this client never had the chance to experience richness and beauty in his 20

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life, yet in life you assumed something was possible and worked as if it were so. There’s a cost that both you and your client paid. You peered out into the future, longing for something marvelous that never came. You and your client feel saddened by that loss. That’s a real cost. Focus now on the lower right quadrant. This time the extraordinary was impossible and you assumed so all along. “Aha! I was right,” you cry. “He really was a hopeless case!” You get to feel good about being right. It seems a small prize. Now look to the bottom left quadrant, where you assumed your client was hopeless but you were wrong. Against all odds, he could have experienced something transformational and extraordinary. Instead, you assumed the least and coached him to accept and pursue some minimal existence. You sold him short. And, finally, consider the upper left quadrant. You held out hope that, against all odds, there was some spark of life, some unrealized possibility available to your client. You and he doggedly sought it out, wondered about its shape. You taught him to wonder, to dream, to feel for a life that was significant for him. And, this time, you were right. That day, you get to see things like I saw them with the client in my story and all the others with variations on that story. There are four outcomes in Wilson’s wager, but only two ways to bet. You either bet yes or you bet no. There are two mistakes possible in Wilson’s wager. One mistake is betting the client can have something extraordinary and being wrong, and the cost is feeling bad. The other mistake is betting the client cannot experience something extraordinary and being wrong. The cost in that quadrant is selling the client short. So you have to decide which kind of mistake you’re willing to make. You need to enter into Wilson’s wager with open eyes. In contrast to Pascal’s, my wager does have inevitable and painful consequences if you bet yes and you’re wrong. If you bet yes, with me, you’ll bury clients. They’ll storm out the door and come to bad ends. You’ll have to watch them slip away, despite every ounce of your very best efforts. All of those outcomes will bring you pain and self-doubt. Yet the consequences of the other option, I think, are too horrific to even contemplate, no matter what pain it might let us ignore. I assume that it’s my job to bet yes on every single client who walks through my door. No matter what. I assume that there’s a way for my clients to live their values under any and all circumstances. I assume that if Victor Frankl could live his values and experience liberation in a death camp, my clients, no matter what their history or circumstance, have that same richness available to them. 21

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SUMMING UP So, pausing a moment, let’s reflect on where we’ve come from. I claim, along with many before me, that suffering is part of life. I’m claiming that it’s in the human condition to suffer and that we’re capable of suffering under any and all conditions. I claim also that it’s in the human condition to resist suffering and that resisting psychological suffering has a cost. I’m claiming that the resistance is pathogenic and exacts a cost in experienced vitality and fullness of life. Further, I’m claiming that liberation is possible, that it’s possible for our clients (and for us) to experience richness, beauty, and a sense of purpose under any and all conditions. So what? Well, if you’re with me so far, it now falls to us to figure out how to best act out our yes bet in the therapy room. I’m arguing that this starts with getting our clients and ourselves to fully show up in the therapy room. In the next chapter, I’ll start laying the foundation for an approach to psychotherapy that I think makes this possible—an approach that gives us the chance to really foster mindfulness for two. What follows in chapter 2, as well as in chapters 3 and 4, is somewhat theoretical. Just so you know, though, I will get to the practical stuff. Chapters 5 and 6 detail practical ways to promote mindfulness in the therapy room, chapter 7 develops a new means of case conceptualization, and chapter 8 goes over three major exercises that I think get to the very core of this work. But first, in chapter 2, I want to go over some of the basic behavioral foundations of what I’m proposing, and then, in chapters 3 and 4, I want to situate mindfulness for two within the context of ACT. I’m grateful for your patience. I hope it will be well requited.

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Chapter 2

A Clinician’s Guide to Stimulus Control

I often introduce myself by saying, in a hushed tone appropriate to a confessional, “My name is Kelly, and I’m a behavior analyst.” I typically follow by asking whomever I’m speaking to not to hold that fact against me. Given the work I do—especially the frequency with which I throw around words like heart, suffering, and liberation—many people are often puzzled by my claim to be a behaviorist. But I find that this is because the core characteristics of the behaviorism to which I adhere—contemporary contextual behaviorism in the tradition of radical behaviorism—are confusing and obscure to a lot of people. (Don’t worry if contextual behaviorism is unfamiliar to you. We’ll touch on it a little later.) Many of the folks I encounter have very firm convictions about the value of behaviorism. Yet they have a far less firm idea of what behaviorism actually is. My hope is to shift this trend, at least somewhat, with this chapter. Brace yourself. This chapter is going to be technical, more so than any that follow it. And the terminology is going to be heavy. I can’t really get around this. My hope, though, is that by becoming more familiar with the basics of stimulus control, your ability to detect subtle shifts in stimulus control in the therapy room—whether in yourself or in your clients—will help you connect more deeply and intimately with your clients, building a strong foundation for mindfulness for two. ACT is the application of contemporary contextual behavioral psychology, a study of behavior focusing on context and function rather

Mindfulness for Two

than form, as it emerged from the tradition of radical behaviorism. In an important sense, ACT is really applied behavior analysis, which is the empirical observation of behavior with the goal of predicting and influencing it. For many years, we didn’t call it that—for some rather compelling reasons. Until recently, if you brought up “applied behavior analysis” in a group of professionals, most of them would say, sometimes out loud, sometimes to themselves, one of two things: “Oh, I know about that already, and I hate it, so I don’t need to listen anymore.” Or, on the other hand, “Oh, I know about that already, and I like it, so I don’t need to listen anymore.” I’d like convince you that there is something important to listen to in applied behavior analysis, whichever side you fall on. If you’re inclined to view behavior analysis as too narrow, mechanistic, and reductionistic, I ask that you keep an open mind. There are a lot of behaviorisms out there, and I think you’ll find that this one may leave out the elements to which you object. If you have a positive view of behavior analysis—or, even, are a behavior analyst yourself—I would request that you join me to look anew at some domains that maybe have gone unexplored or where we, as behavior analysts, drew premature conclusions that satisfied us at the time but failed to exhaust the possibilities of the theoretical model. If you take the time to engage with this material, I promise that it will have a positive impact on the work you do in the service of your clients.

NOT THE BEHAVIORISM YOU THINK YOU KNOW Behaviorism often turns therapists off because it hasn’t particularly been known for its contributions to psychotherapy. When many of us think of behaviorism, we conjure up images of rats pressing levers. When we think of radical behaviorism, we imagine all of the limiting, negative things we think we know about behaviorism—and then we “radicalize” them, making behaviorism seem even more objectionable. In fact, radical behaviorism, developed by B. F. Skinner, is the philosophy that forms the basis for modern behavior analysis. Though perhaps radical behaviorism was unfortunately named, it’s far from limiting. When I encounter people who don’t like behaviorism, I sometimes ask them why. The most common misconception is that behaviorism denies thinking and feeling. And the second is the notion that behaviorism shrinks human behavior down to an atomistic account of Â�punishment 24

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and rewards, a reductionistic process that eventually mechanizes rich and varied human experience, turning us all into robots. If these caricatures are true anywhere in behaviorism—and this is arguable—they’re not found in the behaviorism of B. F. Skinner, and they’re certainly out of place in the contemporary contextual behavioral account I’m Â�describing in this book.

THINKING-FEELING BEHAVIORISM All of us have a fraction of the world to which only we have direct access. Others may see what we do with our hands and feet quite directly, yet they don’t have such direct access to our private events, that is, what we think, feel, imagine, and desire. Any psychology that doesn’t address these matters is likely to be, and probably ought to be, rejected out of hand. But this issue of whether private events are a proper subject of study has been the frequent point of contention in the history of psychology. In the middle of the last century, empirical psychology—in its search for a so-called objective psychology—ran away from questions about this world inside the skin. In a symposium in 1945, the famous historian of experimental psychology Edwin Boring stated, “Science does not consider private data.” Responding to Boring, B. F. Skinner quipped, “Just where this leaves my contribution to the symposium I do not like to reflect… The irony is that while Boring must confine himself to an account of my external behavior, I am still interested in what might be called Boring-fromwithin” (Skinner, 1972, 384). Skinner never disavowed interest in private events, but his was only one voice among many in behaviorism. And many within the broader behavioral movement did call out for an analysis that dismissed our inner life—or at least placed it outside the range of science. It’s very possible that a good deal of the contemporary rejection of behavior analysis has been in reaction to this rigidity, to positions that were held too stridently, to versions of behavioral psychology that truly failed to take human cognition seriously. But, as even Hamlet remarks, “There is nothing either good or bad, but thinking makes it so” (Hamlet 2.2.250–251). Commonsense observation alone suggests that the human capacity for cognition exerts a considerable influence on our behavior. It’s not so far-fetched to imagine that, by neglecting to provide a workable explanation of the role of private events within the framework of Â�behaviorism, the mainstream of this tradition fell into disuse during the ascendancy of cognitive psychology in the latter part of the 25

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twentieth century. Regardless of the reason, the plain fact is that we now find ourselves Â� at a point in time where many—if not most—individuals Â�providing mental health care are not well trained in behavior analysis.

WHY DO WE NEED BEHAVIOR ANALYSIS? So what? What difference would it make if none of today’s clinicians were trained in behavior analysis? It might not make much difference at all but for the fact that contemporary psychotherapy took a turn in the 1990s, the new behavior therapies (of which ACT is one) emerged into the profession, and clinical research started to suggest that this work showed promise. With encouraging research findings came interest, and as interest grew, more clinicians wanted to take advantage of these new and promising technologies. And several of these new therapies formulate case conceptualization from a behavioral perspective. The glasshalf-full view here is that, if you’re interested in these new therapies, an understanding of behavior analysis is a genuine asset for you. But if you’re partial to a more pessimistic worldview, you might say that, without a solid foundation in behavior analysis, you’ll have some serious holes in your understanding and application of these technologies. And if you do, you’re certainly not alone. Basic behavioral training all but vanished from clinical psychology curricula in the last couple decades of the twentieth century.

RETHINKING BEHAVIORAL TRAINING So we have several generations of clinical professionals that may lack a strong foundation in basic behavior science, and we have a number of emerging modalities that depend on theses skills for successful case conceptualization. What can we do about that? There are several different approaches to basic behavioral training. Some are highly technical and make use of the hugely precise language and razor-fine discriminations that are necessary for basic laboratory work. Yet while these technical details are important in research, some are less so outside the laboratory. I’m going to go out on a limb and guess that you’ve not made notes about “a changeover delay in a concurrent VI-2' /VI-2' schedule of reinforcement” on any of your clients’ charts lately. What would be of great benefit to you, especially if you are drawn 26

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to the new behavior therapies, is an understanding the core of behavior analysis: the functional relation between behavior and the contexts in which it occurs. This is what I’ll be guiding you through in this chapter. I want to introduce behavioral thinking in a way that I hope is useful for you if your behavioral training happened a long time ago, was maybe less rigorous than you might now wish, or was not well integrated with clinical work. And, of course, this chapter should be of considerable value to you if you’ve had no behavioral training at all. Along the way, I’ll give you the barest outline of a contextual behavioral perspective from which you can observe your clients’ activities (and your own). As someone trained at depth in both basic behavior analysis and clinical psychology, I think that basic behavior analysis has an important message for applied psychology (of which clinical work is a subset). In what follows, I’ve struck a balance between applicability to clinical work on one hand and technical accuracy and completeness on the other. The material here is directly relevant to both understanding and doing ACT. As we go, we’ll connect technical explanations with clinical examples. By doing this, I hope both to keep these technical distinctions relevant to your practice and to prevent you from lapsing into a technical analysis coma.

BEHAVIOR ANALYSIS: GETTING STARTED The foundation upon which behavior analysis rests is the relatively uncontroversial idea that behavior is influenced by the context in which it is embedded. In a certain sense, behavior analysis can be thought of as a relatively refined language that enables us to talk about behavior and the contexts that influence it. It is, in a real sense, contextual behavioral psychology. Contextual behavioral psychology serves a practical purpose: it helps us make sense of the world around us. As with other scientific perspectives—physics, geology, biology—we (humankind) adopted it because we found it useful to organize the world and its events into categories and into the relations among categories. But make no mistake: the categories and relations you’ll encounter in the following pages are not “true” in the capital T sense of true or, by any means, exhaustive of all human behavior. They serve a practical purpose—to enable us to have the discussion that is behavior analysis—and we can and should let them go when they no longer serve us well. 27

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Behavior analysis is nothing more than a way of speaking about what people do. There are innumerable ways of speaking about what people do, including other scientific ways of speaking like those I mentioned above. In addition to these, there are countless nonscientific ways of speaking— poetry, theology, just plain old common sense. Behavioral ways of speaking ought not be measured against other ways of speaking. Rather, behavior analysis ought to be measured against the ways such speaking can be useful in meeting our goals. In short, when evaluating our use of behavior analysis, or this way of speaking and categorizing, we need to ask ourselves to what extent our analysis helps us in understanding the behavior of clients such that they become free to move their lives in a valued direction.

THE DISTINCTION BETWEEN BEHAVIOR AND CONTEXT Behavior analysis is a precise yet general way of speaking about behavior, the context in which it occurs, and the relations between behavior and context. Since the elements of our analysis will be aspects of behavior and context, it’s very useful to distinguish between the two.

Behavior There are widely divergent views in psychology regarding what is meant by behavior. My own first encounter with behavior was in developing and implementing behavior plans for individuals with developmental disabilities. I was taught in most of my introductory psychology courses that behaviorism confined itself to publicly observable responses— walking, talking, speaking, and the like. My very first course on behavior analysis was taught by Sam Leigland, an early mentor of mine who still teaches at Gonzaga University. Sam is a tall fellow of Scandinavian descent who can turn his entire body into a question mark. So, on the first day of class, this tall Scandinavian question mark turned to us and asked, “What is the subject matter of behavior analysis?” He didn’t wait for an answer. He supplied one emphatically: “The subject matter of behavior analysis is any and all of the activities of the integrated organism! Any and all!” At the time, I was carrying a copy of Man’s Search for Meaning around in my pocket as a sort of compass. I went to Sam’s office after that class and asked him, “What about this? Can behavior analysis help 28

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us to understand what happened to Frankl in that death camp? Can it help us to understand the human capacity to find meaning in the midst of horror?” Sam didn’t give me an answer that day. Instead he gave me a job. The essence of what Sam told me was that if behavior analysis could not make sense of the most profound human activities, then it is not worth much. Sam got me reading papers like “Radical Behaviorism in Reconciliation with Phenomenology” (Day, 1992) and “Making Sense of Spirituality” (Hayes, 1984). He showed me that there was a richness in behavior analysis that was nowhere to be seen in introductory psychology texts. (As I write this, I’m reminded what a great gift my best teachers have been to me.) Often behavior is distinguished from things like thinking and feeling. The behaviorism Sam offered to me, and that I in turn offer to you, says that if an organism can do it, it is behavior. Could a person think, imagine, believe, hope, want, freak out, or feel exuberant, despondent, inspired? Or, like Frankl, could a person find meaning in the midst of a death camp? If the answer is yes, then that is behavior from this perspective, and is an entirely proper subject matter for our science. Behavior is what is to be explained. For our purposes, behavior will be considered an ongoing, evolving stream of activity in dynamic interaction with context. Behavior, so defined, is the dependent variable of our analysis. We will seek the ways in which it depends on, or is organized by, context.

Context Just as behavior is anything that an organism can do, context is anything that can happen to an organism. This includes both what is currently happening and also what has happened to the organism all the way back to the beginning of its existence. From this perspective, context is anything outside of the behavior being analyzed that influences the development, expression, modification, or maintenance of that behavior, including both current and historical context. Context, or some aspect of context, is the independent variable in our analysis. If we want to have an influence on our clients’ behavior, we will need to understand that which influences behavior. We could suppose that behavior just changes on its own or that change will come spontaneously from the client, but if that is all there is to it, what is our job as therapists? 29

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The issue of influencing client behavior has been a sticking point for behavior analysis. Perhaps it sounds manipulative. Sam had a response to that too. He asked me what I wanted to do for people. I told him that I wanted to help them to find meaning. “How?” he asked. “What will you do?” In that simple question, Sam was leading me back from clients’ behavior (meaning making) out into their environment (their interaction with me and the world around them). “What will you do?” is a practical question. This is useful because we are an important part of our clients’ environment. Anything we do to influence our clients’ behavior is done from outside that behavior. We change both the immediate context of a behavior to give clients the opportunity to do something different and, through a series of interactions, change the historical context of a pattern of behavior. The context in which the behavior occurs is your point of impact as a therapist. Context, then, is that which lies outside behavior, and which exerts an organizing influence on the behavior being analyzed.

Context and Behavior Imagine a client comes into your office. He says to you, “I want to die. Every day I get up and I wonder—can I do one more day? And, if I can, how many more can I do after that?” There are a lot of ways you could respond to a statement like that. How might it influence that ongoing stream of your client’s behavior if you threatened hospitalization, if you appeared distraught and frantic when you heard your client’s words, or if your response suggested that your first concern was to avoid liability with respect to your client? And how might it influence your client if you seemed genuinely interested in hearing the heart of his despair? Depending on your client’s history, any of these different responses might produce dramatically different effects on how he responds to you and what actions he chooses to take, if any, because of your encounter. Your client might become angry. He might jump out of the window. He might be calmed—or might feign calm. I mean nothing controversial when I claim that context organizes behavior. Your client behaves, and you respond. Your response is the context for your client’s behavior, and it has an influence. The same analysis could, of course, be made of your behavior. Your client’s behavior is the context in which you yourself behave. Sometimes it’s useful for us to focus on the way in which context impacts your behavior as a therapist, 30

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but for now, let’s stay focused on your client’s behavior. Even when we do look at your behavior, we’ll want to start our analysis with one stream of behavior at a time. It’s simpler and more likely to be useful to do so.

Responses and Stimuli Another way of speaking about the behavior-context distinction is in terms of responses and stimuli. Responses are behavior, or what an organism does, and stimuli make up context, or what happens to an organism. For example, if we hear a phone ring, hearing is the response, and the ringing is the stimulus. This language highlights the practical nature of the context: we distinguish here between stimulus and response only to facilitate our discussion of what is actually a singular event, in this case, hearing the phone. A stimulus is not a stimulus apart from that which it is stimulating, and a response is not a response apart from that to which it is responding. There is no stimulating without responding and no responding without stimulating. Responding and stimulating are a functional unit. So, in this case, there is no hearing (behavior) independent of what is heard, and no what is heard (context) apart from hearing. Thus we’ll consider any behavior that we want to analyze in and with the context. Any part of any event that seems important in our project of prediction and influence will belong either on the behavior side of the equation (a response) or on the context side of the equation (a stimulus). Those on the behavior side are the events that we seek to influence, while those on the context side are the events that do the influencing. If, considering the example above, we wanted to determine how soon someone is likely to answer the phone when it rings and get her to answer more quickly (predict and influence behavior), we would consider the volume of the ringer, the subject’s proximity to the phone, whether she is wearing earmuffs, and so forth (the context in which the behavior takes place).

Two Common Errors in Understanding Responses and Stimuli Two common misconceptions about responses and stimuli are that responses are movements and stimuli are discrete objects. From a �contextual behavioral perspective, these are both incorrect in the most 31

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Â� technical sense. On the response side, standing still is defined as a response if I can demonstrate that standing still, as the response of interest, is capable of being organized by context, which is to say, capable of being provoked by some kind of stimulus. For example, if I give you a five-dollar bill when you stand still and take five dollars when you move and thereby alter the probability that you’ll stand still, then “standing still” meets our definition of behavior: it’s something the organism can do. Also, standing still can be brought under contextual control—that is, it’s in dynamic interaction with a stimulating environment. On the stimulus side, the most common error is to think of a stimulus as an object. We might, for example, see the five-dollar bill as the stimulus that organizes behavior. In a limited sense, this is true, but a more sophisticated way to think of this is that standing still changes the world from one where you can’t buy things to one in which, with your crisp, new fiver, you can. It is that transition from not having the power to buy things to having that power that organizes behavior, not the bill per se. For example, if I gave you a billion dollars, the promise of an extra five bucks would likely no longer organize your behavior, and you would stand still or move as it pleased you. Or if I locked you in a cell where money couldn’t be spent or given away, five dollars (or even a billion) wouldn’t do much to organize your behavior. Why not? Because receiving the five-dollar bill in either of those two contexts wouldn’t change your world in any significant way. In many applications, calling the five-dollar bill a reinforcer of behavior is probably workable. (We should remember that, despite the leaps and bounds of contemporary physics, Newton’s classical mechanics work just fine in most instances too.) However, we want a more sophisticated understanding of the dynamic interaction of responding and stimulating. Why does it matter? The distinction matters because sometimes there’s no object or immediate discrete event to which we can point. Richard Herrnstein and Philip Hineline (1966) carried out a classic experimental example that illustrates this point nicely. In their study, rats were placed in an experimental chamber, and the floor of the chamber was briefly electrified at random intervals. If the rats pressed a certain lever within the chamber, the shocks would come at a slightly increased, though still random, interval. What Herrnstein and Hineline found in the experiment was that lever pressing was maintained in the rats. We cannot understand the maintenance of the lever pressing by appealing to the immediate effects of lever pressing. The most common immediate effect of a lever press was that nothing would happen. In fact, as result 32

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of the shocks coming at random intervals, the lever press was sometimes followed immediately by a shock. Why did the rats press the lever? In simple terms, the rats pressed the lever because doing so precipitated a transition in context from one in which shocks are more frequent to one in which they are less frequent.

SEEING PATTERNS IN RESPONSE AND CONTEXT In clinical settings, the contextual events (the stimuli that organize your client’s behavior) will frequently not be nice discrete objects. You’ll seldom have the luxury of seeing an M&M dispensed in the therapy room with the press of a lever. I sincerely hope that you won’t see your clients respond to intermittent electric shocks. What you will see, though, are transitions in patterns of responding. And where you see the transition, that’s where you’ll look for organizing context. What are we seeking as we listen to our clients’ stories? How do we find the organizing context? In some respects, a behavior analyst’s job is one of pattern recognition. Although I am interested in the content of my client’s responding, I am even more interested in the patterns of response—including the patterning of content—and the patterns of the contexts in which they are embedded. I have a particular interest in stereotypy, that is, in repeated patterns. These patterns can be quite fascinatingly complex and varied. Ask yourself these questions about your client’s responses:

• Is there a particular pitch and pace to her responding? • Does he complain and complain? • Does she ruminate and ruminate? • Is the topic the same, over and over again? • What is the physical posture he assumes as he conveys his story to me?

These are just a few possibilities of patterns. It’s likely that your client will exhibit several patterns. Can you recognize them? Could you characterize them in terms of pitch, pace, tone, and content? This is the task we have at hand: to make useful observations about the behavior that our clients bring into the room. 33

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Metaphorically speaking, the activity of observing behavior is like listening to a bit of music. You might listen for the bass line and for a moment let go of the lyrics and the flashier lead guitar. Can you listen and let it move you? Tha-thump, tha-thump goes the bass guitar in the background. Can you hear that patterning of response? Once you hear that pattern, can you bring your attention to the context side of the behavior-context interaction? The sound quality of the hall, the ambient noise in the background, the shuffle and rustle of the crowd? Can you listen for both behavior and context at the same time? Focus on both the music and the room? Yes, of course, but remember that dividing your subject matter into behavior and context is a pragmatic matter. Attending to one side of the interaction at a time is simpler. As you get better at it, you can begin to see the ebb and flow of interaction, but it is best to start with a simpler set of discriminations. Two pieces of context are particularly relevant. First, what’s going on in the story the client is telling? What is the context in which the story occurs? Is it a social context? Is it a context involving intimacy or potential intimacy? Is it a time when she is alone and has nothing to do? Is it a context in which he is being evaluated by a supervisor, a parent, or an acquaintance? And, second, when does this pattern come up in session? What was your interaction with the client when this pattern emerged? Are there certain topics that precipitate the client’s behavioral pattern? Do certain emotionally laden issues precipitate the pattern? Are there things going on in your relationship with the client that seem to precipitate this behavioral pattern? What you’re seeking are patterns of context that are correlated with patterns of behavior.

WATCH FOR TRANSITIONS If you think about behavior as being in dynamic interaction with context, you can assume that when you see a transition in responding, there has been a transition in context. With nonhuman species, this is often obvious. The birds are chirping, and they suddenly stop. You look around and see a cat sneaking up through the grass. The dog is lying in its bed, then jumps up and runs to the window. Moments later you hear a delivery truck pull into the driveway. The cat is sleeping on the sofa. You begin to open a can with the electric can opener, and the cat comes running. All of these are examples in which the transition in the environment organizes a transition in behavior—and the transition in 34

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environment—the cat sneaking up, the delivery truck arriving, the can opener whirring—is quite obvious. With humans, a transition is often not so obvious. You may sit and listen to your client describe her week. At some point in the conversation, you note a change in pace or tone. Suddenly she becomes very animated or very anxious. Or perhaps you’re asking about a client’s visit to a friend and see him become momentarily emotional. Why? Sometimes it may be quite obvious what precipitated the transition, but sometimes it isn’t at all clear. As you delve more deeply into the ways context organizes behavior, you’ll begin to see how you can look for particularly telling transitions in behavior. Neither therapists nor clients are typically skilled at detecting subtle shifts in context and the influence they exert over behavior. However, such skill can be cultivated. Noticing such transitions in behavior can lead you to understanding what precipitated them and to which interventions would be called for when you see them.

CONTEXT: ANTECEDENTS AND CONSEQUENCES Within the broad category of context, several distinctions can be made. The simplest of these involves distinguishing whether the relevant stimulating context occurs before the behavior of interest (antecedent) or after the behavior of interest (consequence).

Antecedent Stimulation Some client behavior is under antecedent control. Antecedents are stimuli that come before a response or pattern of responding that change the likelihood that the response pattern will occur. For example, a gunshot increases the likeliness that a startle response will follow. There are other kinds of antecedents too. For example, if the phone rings, we are likely to answer it. Both the gunshot and the ringing are antecedents, but as we shall see, there are important differences in the kinds of behavior they precipitate. The gunshot has a sort of automatic effect on behavior. Gunshot—startle. Gunshot—startle. We call this particular kind of antecedent an eliciting stimulus. The ringing of the phone is different. If the phone rings, we will probably answer it but maybe not. If we have a lot of other things to do, if a particularly good program is on the 35

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television, or if the caller ID says “blocked,” we may not answer. We call this sort of antecedent a discriminative stimulus.

Consequential Stimulation Some client behavior is under consequential control. Consequences are stimuli that follow a response and change the probability that the response will occur again. Depending upon the effect on behavior, we call these consequences reinforcers or punishers. Stimuli that follow a response and increase the likelihood of a response are called reinforcers. For example, praise could be a reinforcer for a child’s reading if it increased the probability of reading. By contrast, stimuli that follow a response that reduce the likelihood of a response are called punishers. A painful burn could be a consequence that would reduce the likeliness of touching a flame. These responses occur because the world changes in some important way when they happen. When a man yells at home, his wife and kids make no more demands on him. When a child cries, the parents allow another hour of television. These examples illustrate ways in which behaving (man yelling, child crying) changes the world, and how that change or transition in context (no more demands, another hour of television) influences the likelihood of that response happening again. There’s a link between consequences and antecedents. Sometimes an antecedent, like the ringing of the phone, signals an available consequence. Discriminative stimuli and consequences go together. When the phone rings and I answer it, there are consequences. My world changes from one where I don’t get to talk with you into one where I do get to talk with you. This doesn’t happen when I answer the phone when it isn’t ringing. It seems so unfair!

BEHAVIOR: RESPONDENT AND OPERANT CONTROL We can also look more closely at the behavior that’s linked to antecedent and consequential stimulation. (Stop and take a deep breath. I know this is getting a little dense and theoretical, but I promise that I’ll bring this back to the therapy room and show you why it’s essential to understand these distinctions. And breathe. Don’t you feel better now?) 36

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Like stimuli, responses can be divided into two major categories. Some patterns of responding are primarily sensitive to antecedents. Other patterns of responding are sensitive to both antecedents and consequences.

Behavior Under Strong Antecedent Stimulus Control Some responding is mostly sensitive to antecedents but relatively insensitive to consequences. Remember that gunshot and the startle response? What if I threatened to take one hundred dollars out of your wallet if you were the least bit startled when the gun went off? The gunshot would still produce a startle response. That startle response is just not very sensitive to consequences. You might be able to restrain it some. It’s not perfectly fixed, but it is relatively insensitive to that aspect of context we call consequences. Behavior of this sort has an almost mechanical quality to it. If the stimulus happens, the response happens with near 100 percent certainty. Depending on the stimulus, if it is presented again and again in rapid succession, the response may get smaller over time. However, generally speaking, a period of time without the stimulus will restore the response to its original strength. This sort of strong antecedent stimulus control is sometimes called respondent stimulus control, and the behavior it controls is called respondent behavior. Behavior under strong antecedent stimulus control can occur with no learning history. This would be the case, for example, if you got startled after hearing a loud noise. We call this unconditioned respondent behavior or an unconditioned response (UCR), and the relevant stimulus an unconditioned stimulus (UCS). However, such behavior can also be learned. For example, if you were bitten by a dog, seeing a dog later might produce strong arousal. If you were in a serious car accident, you might become fearful of driving. Driving isn’t innately fearsome, but it may become so when it’s paired with something that is fearsome, like an accident. Of course pleasurable things can also be conditioned. Cases like all of these are sometimes called classical conditioning, and the resulting behavior is called conditioned respondent behavior or a conditioned response (CR), and the relevant stimulus that was previously neutral a conditioned stimulus (CS). In addition, humans often become fearful even without any direct experience of the feared object. For example, many people are afraid of snakes, even without any direct painful experience with snakes. There 37

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are documented cases of snake phobias where the individual has never even seen an actual snake. Not only can humans become fearful of things they’ve never encountered, they can even become fearful of things that don’t exist: demons or monsters under the bed, for instance. If you think about your difficult clients and the things that generate near-mechanical reactions in them, the overwhelming majority of the events that precipitate these reactions are learned, not unlearned. They are conditioned respondent behaviors. Some of these responses don’t necessarily involve very direct learning histories, but they are, nevertheless, learned and therefore conditioned respondents. Conditioned respondent behavior will be of particular interest to you in your clinical work. It differs from unconditioned respondent behavior in that it is much more malleable. If a person were to interact in a variety of ways with a conditioned stimulus without the unconditioned stimulus, the strong antecedent stimulus control would be reduced over time. For example, if a tone were reliably followed by a shock, the tone would begin to produce a stereotypical startle response. If the tone were presented many times without the shock, the startle response would diminish. The narrow patterning of behavior will be extinguished, leaving the stream of behavior more sensitive to other aspects of context.

Responding Under Both Antecedent and Consequential Control Some responding is sensitive to both antecedents and consequences. For example, if you bring the phone to your ear and get to converse with someone you enjoy, you will be more likely to pick up the phone again because doing so previously has resulted in an enjoyable conversation. You do not, however, walk around with the phone held to your ear all day. You wait for it to ring. The ring signals the availability of the enjoyable conversation, which makes putting the phone to your ear more likely when the ring occurs. Holding the phone to your ear is sensitive both to the antecedent ringing and to the consequential enjoyable conversation. The absence of either the antecedent or consequential conditions is related to decreases in probability of the response. Remember, as we discussed above, this sort of behavior typically has more flexibility and more sensitivity to other conditions (you’re busy, a movie is playing on TV, and so forth). We call this sort behavior that is sensitive to both antecedents and consequences operant behavior. 38

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AVERSIVES, APPETITIVES, AND ABUNDANCE In addition to being distinguished in terms of whether they precede or follow the behavior in question, antecedents and consequences can also be distinguished in terms of their effects on behavior. Appetitive stimuli are what we call stimuli that an organism will work to produce. Aversive stimuli are those that an organism will work to stop, postpone, or attenuate. There are some critical differences between behavior under aversive control and behavior under appetitive control. Understanding these differences can make you a better clinician. Patterns of behavior under strong aversive control tend to be relatively narrow, relatively inflexible, and relatively insensitive to consequences—with the exception of consequences that discontinue, reduce, or postpone the aversive. If I shot a gun off in the room while you were watching television, notice what would happen. First, you’d probably show a very strong startle response. That startle response is a good example of strong antecedent stimulus control. Second, you’d stop doing just about everything else. For example, you might be noticing the smell of dinner cooking, you might be shopping on the Internet on your laptop, you might be sipping a cup of coffee. All of these responses would stop immediately. Strong aversive stimuli have an overall suppressing effect on the patterning of behavior. One exception to this suppression is escape. In the presence of strong aversive stimuli, learned or unlearned, behavioral patterns become relatively narrow, relatively inflexible, and relatively insensitive to various aspects of context, except those aspects of context that are related to the aversive itself and to escape. So in the gunshot example, you might have shown considerable flexibility in your patterning of behavior before the shot as your attention moved from the television to your laptop to smells emanating from the kitchen, and so on. After the shot, all of those things would disappear psychologically. The only things that would be psychologically present would be the gunshot and the exit. An interesting program, a really great bargain online, or the smell of the roast chicken being pulled from the oven would have little influence over your behavior. All of your attention would be focused on whichever exit was closest to you and furthest from the gun-wielding maniac. Just because aversive control tends to result in narrow behavioral repertoires doesn’t necessarily mean that all appetitive control results in broad, flexible ones. In fact when deprivation is particularly high, as with starvation, or where even minor deprivation is experienced as very aversive, such as with drug dependence—it often results in the same 39

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Â� narrowness of repertoire we find with aversive control. The greatest breadth of behavioral repertoires tends to occur when behavior is under the appetitive control of many sources of stimulation that the organism will work to produce—ample food and security, an engaging environment, and so forth. Note, however, that abundance of reinforcement is not defined independently of the behaving individual. Abundance is a psychological factor, not one that can be defined by a physicist. A rich social environment might seem to be a source of abundant Â�reinforcement. Even when people live among many others, though, they Â�sometimes experience themselves as being cut off, isolated, and alone.

RESPONDING UNDER MULTIPLE SOURCES OF CONTROL The distinction between responses mostly sensitive to antecedents and those sensitive to both antecedents and consequences is purely functional. I don’t intend to imply that these types of behavior actually exist as separate entities. You are one organism. You have but one stream of behavior, and there is a constant, evolving, dynamic interaction between your pattern of responding and the context within which it is embedded. Your behavior could at any given moment be sensibly described as being under multiple sources of stimulus control. If we looked carefully, we’d likely find that all of your responses are under multiple sources of control, influenced at least partially by both antecedents and consequences. It is the ebb and flow of patterns of responding and patterns of stimulus control that interests us. I make these distinctions between different kinds of stimulus control because different behaviors that your clients exhibit will show sensitivities and insensitivities, just like the ones I’ve described. If your client’s behavior is under strong antecedent stimulus control and you warn her about consequences or point out past consequences of engaging in that behavior, it’s not likely to have much effect. Behavior under strong antecedent aversive control is like that, along with behavior under appetitive control where deprivation is high. By definition, those patterns are not sensitive to consequences (except possibly escape). Also, it’s not the form of these behaviors that distinguishes them, but rather their functional relationships with the different aspects of context. A particular behavior could look the same on the outside, but could be, in some conditions, under antecedent control and, in other conditions, 40

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sensitive to both antecedents and consequences. For example, you might stub your toe walking down a bumpy sidewalk and begin to cry because of the pain. You may also get pulled over by a policeman and begin to cry because, in the past, you’ve escaped a ticket by crying. Crying outside of its context cannot be distinguished as either under antecedent or consequential control. With context, however, the distinction can be made. In the first situation, crying is under antecedent control, and in the second, it is under consequential control. At other times still, the same behavior may be under both sources of control. It’s less important to determine if a behavior is an example of respondent or operant control and more important to discern degrees of control and sensitivity. Likewise, you cannot determine the meaning of client behaviors without looking to the context in which those behaviors are exhibited.

PUTTING IT ALL TOGETHER Most psychopathology shares some restriction in range of behavior. Those with alcoholism may drink and drink; people with obsessive-compulsive disorder may wash and wash; folks suffering from major depression may stay in bed all day. The problem with alcoholism isn’t drinking per se, it’s having to drink. It’s having to wash one’s hands rather than hand washing itself that’s the problem with obsessive-compulsive disorder. And that people with depression stay in bed all day with the covers pulled over their heads is really a matter of little consequence in and of itself. Staying in bed all day is delightful. I recommend it. Sometimes on vacation, I get a nice fat novel and spend a day where I get up only to eat and go to the bathroom. Ah! No, once again, the problem isn’t staying in bed. The problem is having to stay in bed. The problem is the dread that overcomes the person as he pulls the blankets off, drapes his legs over the side of the bed, and lets his feet touch the floor. To just roll back into bed would give such relief, with perhaps a promise to get up later. And in that moment, the act of surrendering to depression buys a little peace. Even with difficulties typified by erratic behavior, like the dramatic cluster personality disorders, the thing that causes problems is that these individuals are systematically erratic. Try to get a client suffering in these ways to slow down a bit! Marsha Linehan, the founder of dialectical behavior therapy (DBT), has spent her career developing technologies that facilitate that process among just such clients. Setting aside the categories of problem behavior, there is a stereotypy (repeated pattern) that 41

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cuts across categories. It may have many different forms, but the narrowness of the pattern is suggestive of behavior under strong antecedent aversive control. Take the example of a snake phobia. The defining features of a snake phobia are arousal and avoidance in the presence of snakes. A typical conceptualization of an exposure-based treatment is that as the phobic individual begins to interact with snakes in a variety of different ways, the probability of arousal and avoidance decreases. This process can also be construed more broadly, considering the range of responses that might be in the person’s repertoire. People can feed snakes, pet them, talk about them, study them, read about them, watch them, and so on. With this in mind, snake phobia can be defined not merely by the presence of arousal and avoidance but also by the narrowness and inflexibility of the range of behaviors in which the individual engages. Likewise, the effects of exposure would not merely involve a decrease in arousal and avoidance but also an increase in the probability of alternative responses. With our clients, however, it’s not typically events that are intrinsically aversive, that create this narrowness and inflexibility. Rather, it’s aspects of context—such as painful thoughts, feelings, memories, or physical sensations—that are experienced inside the skin. A client may, for example, be interpersonally engaging and facile during sessions until the memory of an abuse experience shows up. Suddenly that individual begins to exhibit affective, verbal, physical, and attentional inflexibility, just as if she had suffered an electric shock or other external aversive. Some ACT interventions, such as values work, are about consequences. Specifically, they are about reinforcers. However, if the pattern of behavior we see is under strong antecedent aversive control, talking about values (that is, reinforcers) will have little effect. In fact, if the person notices how his own behavior precipitates costs in some valued domain, that too will be experienced as aversive, and narrow behavior even more so. If you can encourage this individual to sit quietly in the present moment and to experience the difficult emotion with acceptance and openness, then the strong antecedent stimulus control will lessen. As it does, you’ll see the gradual emergence of flexibility in affect, speech pattern, physical posture, and other aspects. Now, if you begin to gently ask questions about valued living, those questions are much more likely to be received in a more flexible and open way. Being sensitive to the stimulus control being exerted can help to direct your interventions so that they are responsive to the stream of 42

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behavior occurring in that moment. You’ll need to cultivate a sensitivity that stands in stark contrast to the rote execution of a series of interventions. Changing behavior under antecedent control requires different interventions than changing behavior that is under consequential control. Those sources of stimulus control will come and go many times over the course of a single session. Attention to both types of behavior is necessary to help free up your clients to cultivate and pursue their values.

STIMULUS CONTROL AND THE CLINICIAN Having sufficient sensitivity to detect subtle shifts in stimulus control can sound daunting. As is true elsewhere in the ACT model, the principles that apply to clients apply equally to clinicians. In fact, if you can learn to detect the coming and going of aversive control inside your own skin, you’ll be better able to detect and treat your clients with sensitivity. In fact, your own reactions are the most sensitive instrument you have in that room. Think about the last client you had who told you that she wanted to kill herself. What happened to your repertoire when those words came out of her mouth? Close your eyes for a moment right now and notice what happens as you think about them. Can you feel your chest tighten just a bit? Can you feel yourself wanting to move to the next section? That’s what aversive control feels like. The time when your behavior will most likely come under aversive control is when your client’s behavior is under aversive control. It is a painful fact, but your own experience is a sensitive instrument in making the discriminations I’m talking about. Generally, awareness of changes in stimulus control is a clinical asset, and mindful awareness is a means of becoming more sensitive to these changes in control. So don’t forget everything you’ve just learned about stimulus control. It matters! In the next chapter, we’ll look more specifically at ACT processes and see how these fit with this more basic technical analysis of behavior, and we’ll also take a look at mindfulness from an ACT perspective.

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Chapter 3

The Hexaflex Model and Mindfulness from an ACT Perspective

ACT is currently thought of as the convergence of six core processes: acceptance, defusion, self-as-context, values, committed action, and contact with the present moment, which is quite central to mindfulness. These six core processes are often represented graphically as a hexagon (see the illustration near the end of this chapter) and have come to be known collectively as the hexaflex model. Although they are described individually, we misinterpret the theory if we think of these six processes as independent of one another. Remember that ACT has functional contextualism at its theoretical core, which means that the organizational structure of the six processes is of interest only to the extent that it serves our purposes in a given context. The divisions we make in the process model, an ostensibly unified event, are made for purely practical reasons. Breaking the model up into manageable parts allows us talk about the whole process picture in a manageable way. Yet, as we’ll see, all of the processes are entailed in all of the others. In comparison, we might analyze running in terms of its speed, rhythm, and biomechanics. But the running is still one thing. Speed, rhythm, and biomechanics are ways of looking at the unified act of running. In a certain sense, they are inseparable from one another. Likewise the six ACT core processes ought to be thought of as analogous

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to a gem cut into six facets. You could look into any of the six facets, but what you would see in that facet would be the reflections of each of the others. In this chapter, we’ll examine a stream of behavior by looking through each of these facets or core processes. I don’t make these distinctions because these six are the fundamental “atoms” of behavior, but because ACT holds that these are useful perspectives to take on behavior. The basic distinctions we looked at in the previous chapter are like that too. They’re simply perspectives we can take on behavior, not the “atoms” of behavior. We expect that there are many ways to view and understand behavior that might be more useful for different purposes. Spiritual and poetic understandings of behavior might, for example, be more useful in some domains. The language used and the perspectives taken in this chapter and in chapter 2 are intended to be useful for the development of a science of behavior and for the orientation of practitioners. Beyond those particular uses, I make no assertions about these distinctions.

ACCEPTANCE Let’s begin our examination of the six ACT processes from the hexaÂ� flex with acceptance because acceptance is where the model began. Acceptance processes involve taking an intentionally open, receptive, nonjudgmental posture with respect to various aspects of experience. In ACT, acceptance is typically spoken of in terms of experiential acceptance and its counterpart, experiential avoidance, which we’ll look at more closely below. The “experiential” reference in experiential avoidance is used to distinguish the nonacceptance of private events, such as thoughts, from the nonacceptance of events in the external environment, such as an abusive relationship. Experiential avoidance is not limited to cognitive avoidance. It also includes other aspects of experience, such as bodily sensations, memories, thoughts, images, and behavioral predispositions. Behavioral predispositions are that cluster of thoughts, emotions, and urges that typically precede some act. For example, drug addicts might experience a whole array of thoughts, emotions, and bodily states and have a sense of inevitability that they will ultimately choose to take drugs. Similar experiences can be found clinically in all of the impulse disorders, such as eating and gambling, and in a lesser form in all of us as we gaze at the chocolate cake and wonder whether we will have just one more slice. Of course, immediate relief from that discomfort is available—simply take drugs, gamble, or 46

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eat. When such acts are done in the service of managing these difficult experiences, we call that experiential avoidance. In practice, acceptance of both internal and external events may serve an individual’s values. For example, Frankl accepted internment in a Nazi death camp in the service of caring for his patients. It is often the case that acceptance or change of external events can be served by acceptance of internal events. Some research data may help support this conclusion. For example, one study found that increased mindfulness on the part of parents produces more effective child management skills (Singh et al., 2006). In addition, some workplace stress studies have shown that employees receiving an acceptance-oriented intervention went on to show substantial improvements in workplace innovation (Bond & Bunce, 2000; Bond & Flaxman, 2006).

Acceptance Isn’t Approving, Wanting, or Liking When we’re speaking to clients, it’s important to be clear what acceptance is—and especially what it isn’t. Speaking of acceptance can easily be heard as changing your opinion or evaluation of some negative event. We need to distinguish acceptance from approval, wanting, or liking. One may accept thoughts about a cancer diagnosis without approving of cancer and certainly without wanting or liking cancer. Acceptance, as we mean it in ACT, is independent of judgment and desire. This includes both positive and negative judgments. Acceptance means that when a particular experience arises, we can acknowledge it, be present to it, and take it in without attempts to alter it in any way. We may have judgments about the thought: “I don’t like it!” However, having a negative judgment about a thought is not equivalent to experiential avoidance. Experiential avoidance would involve acting to reduce, eliminate, or control the thought.

Acceptance Isn’t Resignation Another subtle distinction is between acceptance and resignation. Resignation involves some aspects that are similar to acceptance. For example, if you are resigned to something, you may no longer fight it. However, resignation often involves a sort of giving up on life and on possibilities. Acceptance in ACT is more like opening up than it is like giving up. 47

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Why Is Experiential Avoidance Important? Experiential avoidance can interfere with valued living. (And here we begin to see examples of how the different core processes reflect and affect each other.) Experiential avoidance is important when that which is unacceptable lies between us and the things we value. For example, a person with a history of childhood sexual abuse might occasionally experience thoughts, memories, and bodily sensations related to the sexual abuse. These might be more likely to occur in situations involving physical intimacy or perhaps even in settings where physical intimacy was imminent or even possible. Yet it may also be the case that this individual values a relationship of which physical intimacy is a part. Avoiding these behaviors to reduce or control the private events associated with sexual abuse may do something to moderate discomfort in the short term, but it may also stand in the way of a chosen valued direction. If a person were completely unwilling to have those thoughts, he could act to reduce or eliminate them. When we describe that which is unacceptable, we describe the edges of the world we are free to inhabit. To deem thoughts and emotions related to sexual abuse unacceptable means that the person cannot go where those thoughts are likely to emerge. It might mean that the person will avoid intimacy, struggle to suppress those thoughts, or perhaps to even dissociate during intimate relations. If the person values intimacy, nonacceptance of those thoughts, emotions, and bodily states is a barrier to the pursuit of intimacy. Under some circumstances, experiential avoidance can make bad things worse. There’s a growing body of literature that suggests that attempts to suppress negative thoughts and emotions can have detrimental effects (Purdon, 1999; Roemer & Borkovec, 1994; Wegner, Schneider, Carter, & White, 1987). There’s also a body of evidence that suggests that openness and acceptance fosters good long-term outcomes (Gifford, Ritsher, McKellar, & Moos, 2006; Hayes, Bond, Masuda, & Lillis, 2006). For example, James Pennebaker pioneered a series of writing studies in which participants wrote about difficult situations. Most of the studies involved participants writing about a difficult topic for approximately twenty minutes on three separate days. In their writing instructions, they were encouraged to write about their deepest feelings regarding the difficult topic. Pennebaker and other researchers have found quite surprising results. A group of workers laid off from their jobs who wrote about the pain of being laid off were reemployed more rapidly than workers who didn’t do this writing (Spera, Buhrfeind, & Pennebaker, 1994). College freshmen 48

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who wrote about their difficulties in school showed fewer health care visits and better grades (Pennebaker & Beall, 1986).

Is Experiential Avoidance Bad? We should be cautious about overextrapolating from these data and crusading to help everyone around us emote and express every difficult experience. A good recent example can be found in the literature on critical incident debriefing, which has been shown to actually cause harm to some individuals receiving the treatment (Rose, Bisson, & Wessely, 2003). Likewise, not all individuals or populations in Pennebaker type writing studies show benefits. From an ACT perspective, experiential avoidance is neither good nor bad in itself. Experiential avoidance is bad when, if, and just to the extent that it interferes with valued living. It’s relatively simple to think of instances in which experiential avoidance is entirely benign. Distracting yourself at the dentist’s office by looking at the ski poster on the ceiling, taking a mild sedative before the appointment, or asking for nitrous oxide has little negative impact on your dental work or probably any other value, even if it’s done in an attempt to reduce anxiety.

Acceptance in Behavioral Terms Difficult psychological experiences are likely to generate the sort of strong antecedent aversive control I described in the last chapter. As you’ll recall, such stimulus control generates relatively narrow and inflexible patterns of responding. Also, behavior repertoires like these are less sensitive to aspects of context other than the difficult material and ways to reduce contact with it. This is precisely why experiential avoidance is often at odds with valued living. Many domains of valued living, such as intimacy, are enhanced by moment-by-moment sensitivity. To speak in a very ordinary way, it would be tough to be the most sensitive lover if you were busy suppressing thoughts of abuse. In behavioral terms, acceptance is an alternative response to difficult psychological experiences.

Reflections on the Clinician Consider the value you’re pursuing as a therapist while in the room, working with a client. I’ve suggested that you’ll see subtle shifts in the 49

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patterning of your client’s behavior during a session. If your own behavior is under strong antecedent aversive control, it’s much more likely that you’ll miss these transitions. For example, if you’re in the room busily trying to look competent, it’s more likely that your interventions will be less sensitive to subtle changes in your client’s behavior. Paradoxically, you will be less competent. This is a good place for you examine some of your acceptance issues as they affect you in sessions with your clients. Please reflect on these questions:

• Would you rather feel incompetent or be incompetent? • What if being willing to accept feelings of incompetence were the admission price to greater competence?

• Would you be willing to pay that price—for the sake of your clients and for your own sake?

Don’t rush to answer these questions. Just hold them lightly for a while and see what shows up for you. When you’re ready, ease into the exercise below. Consider first the things to you tend to avoid when you’re in session with your clients. Then think about what behavior repertoires you engage in to keep these hard things away from you. Finally, consider what the real consequences of this avoidance have been, both for you and for your clients. I really encourage you to take your time with this. It may be very hard for you, but if you’re inventorying these things in the service of something you value—namely being an instrument of change in the lives of your clients—I think you’ll be rewarded.

EXERCISE: Reflections on Acceptance Mull over or write in your journal about the following questions:

• What are the biggest things I avoid in session? • What behavior repertoires do I use to keep these hard things away?

• What have the consequences of these choices been?

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DEFUSION Defusion means making contact with verbal products as what they are, not as what they say they are. By extension, defusion’s opposite, fusion, means taking these verbal products very literally, investing them with authority and consequence. I know this definition sounds daunting and technical, but we can look at it in a less technical way. Verbal product just means that some event, either internal or external, has meaning as result of verbal learning processes. Sometimes “verbal” means actual words, like a thought you might have (for example, I think I’ll skip this section of the book). Things other than words can also be verbal from this perspective. So, for example, if you felt a palpitation in your chest, what you just experienced is a physical sensation. However, if a friend recently had a heart attack, the palpitation might be experienced as bad, frightening, or a precursor to a heart attack, or as an occasion to go to the doctor, to increase your life insurance, to rethink eating that second donut, to start an exercise program, to start taking your blood pressure medication again, and so forth. All that from a little physical sensation! How did that sensation come to mean all those things? Largely through verbal learning processes. Words have an amazing capacity to make monsters present. We confuse words with the things that the words point to. We do this sometimes when the thing pointed to doesn’t even exist. There was a time when many people wouldn’t sail far out to sea for fear of falling from the edge of the flat earth. Zen teachers sometimes say that the finger Â�pointing at the moon isn’t the moon. We might need to go further still— the finger pointing at the moon isn’t the moon, and, further, even the moon isn’t the moon.

Why Should We Care About Fusion? Just so we don’t drown in a sea of abstraction, let’s look at the ways we see fusion in clinical examples. If someone with agoraphobia responds to the thought that she’s having a heart attack as if she’s actually having one, she’ll go to the hospital again and again. If a student sitting in a classroom has the thought that everyone in class understands except him and acts as if that thought is so, he remains quiet and benefits less from the class. This seems to raise issues related to the veracity of the thoughts. Imagine, however, in the classroom example, if it were actually the case that everyone else understood. Remaining silent would still be 51

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ineffective if the value being pursued were being educated. In ACT, we’re concerned much more with workability then veracity. What, though, is to be done with such troubling thoughts?

Contrasting ACT and Traditional Accounts of the Role of Cognition Traditionally, cognitive therapists have focused on the veracity of thoughts and encouraged a dialogue and series of behavioral experiments that are aimed at examining and ultimately refuting inaccurate thoughts. The core change mechanism is the supplanting of negative and inaccurate thoughts with more positive and accurate ones, with the assumption that altering the content of thoughts will alter behavior and emotion. The underlying assumption in cognitive therapy seems intuitively obvious. It’s consistent with cultural admonitions to take a positive attitude and to be certain of the facts before taking action. Yet this model has come under increasing scrutiny in recent years.

The Example of Self-Esteem Consider, for example, the movement to improve self-esteem. Programs to raise self-esteem have proliferated all over the United States for the past thirty years. However, just because it’s true that having positive thoughts about oneself is correlated with positive outcomes doesn’t mean that interventions aimed at generating positive self-concept will necessarily produce those outcomes. The following was a conclusion drawn in a recent meta-analysis of the self-esteem literature: We have not found evidence that boosting self-esteem (by therapeutic interventions or school programs) causes benefits. Our findings don’t support continued widespread efforts to boost self-esteem in the hope that it will by itself foster improved outcomes. In view of the heterogeneity of high self-esteem, indiscriminate praise might just as easily promote narcissism, with its less desirable consequences. Instead, we recommend using praise to boost self-esteem as a reward for socially desirable behavior and self-improvement. (Baumeister, Campbell, Krueger, & Vohs, 2003) 52

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The Example of Cognitive Therapy Cognitive therapy, more so than any previous therapy model, focuses on cognitive change as the central mediator of clinical improvement. I’ll offer a critique of cognitive therapy, but I want you to understand that I do so holding close the words attributed to Bernard of Chartres and repeated through the centuries by the likes of George Herbert, Isaac Newton, and Samuel Taylor Coleridge: we can see further than giants when we stand on their shoulders. In that light, please recognize that I know that this critique wouldn’t even be possible except for the remarkable and forward-thinking work of individuals like Aaron Beck and Albert Ellis, among others who rightly asked about the role of human thinking in psychological problems. Contemporary variants of cognitive behavior therapy (CBT) share this view: “Only in instances where cognitive change can be demonstrated, and where cognitive mediation is an important component of the treatment plan, can the term ‘cognitivebehavioral’ be applied” (Dobson & Block, 1988, 7). Although cognitive therapy focuses on cognition as the key mediator of change, it has always included direct behavioral interventions in the form of behavioral experiments. Behavioral activation, a behavioral component of traditional CBT in which clients develop a hierarchy of reinforcing activities and then set goals within that hierarchy as a means of reconnection to naturally occurring sources of reinforcement, involves activities done outside session that have the potential to disconfirm irrational negative beliefs. Other interventions aim at relatively situationÂ�specific negative automatic thoughts (NAT). A large number of variants of automatic thoughts have been identified, including selective abstraction, maximizing, minimizing, and overgeneralization—and the list goes on. Still other cognitive therapy interventions target core cognitive schemas, fundamental cognitive structures relevant to a person’s construction of self, others, the future, and the external world. In deconstructing cognitive therapy into its constituent parts, the late Neil Jacobson attempted to test whether direct intervention on cognition, both local (NAT) and global (core schemas), could account for improvement in cognitive therapy. He designed a study that used three conditions in the treatment of depression. The first involved the full cognitive therapy package, including work on behavioral activation, intervention on negative automatic thoughts, and finally work on core schema (we’ll refer to this one as CT). A second treatment condition involved only the behavioral activation and negative automatic thoughts components (NAT). A third and final condition involved behavioral 53

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activation (BA) alone with no cognitive interventions allowed (Jacobson et al., 1996). At posttreatment as well as at a two-year follow-up, “the three treatment conditions were virtually identical on every criterion measure, including recovery and relapse rates, number of well weeks, and survival time to relapse” (Gortner, Gollan, Dobson, & Jacobson, 1998, 380–381). The authors concluded that “the full CT package was no more effective at preventing depressive relapse or recurrence than either of its component parts” (Gortner et al., 1998, 381). The efficacy of cognitive therapy was not called into question in this study. In fact, the outcomes in Jacobson’s trial were comparable to outcomes in previous trials that demonstrated the efficacy of cognitive therapy. It was the mechanisms by which cognitive therapy works that were called into question as Jacobson asked whether direct cognitive interventions added anything to the treatment. A more recent study examined the differential effects for CT versus BA for low versus high levels of depression. For individuals with low levels of depression, the study showed the same equivalence of outcomes as Jacobson and colleagues. However, for high levels of depression, BA alone actually outperformed the CT condition (Dimidjian et al., 2006). Questions about underlying mechanisms of cognitive therapy are not new and are not restricted to critics of the theory. These questions also come to us directly from the originators of the model. In 1986, Steven Hollon and Arron Beck stated that “there is not, as yet, compelling evidence that cognitive therapy works, when it works, by virtue of changing beliefs and/or information processing, although that remains a very viable possibility” (446–448). And in 1994, they said, “It is not clear whether these interventions work, when they work, by virtue of changing beliefs or thinking, as specified by theory” (Hollon and Beck, 1994, 458).

An ACT Perspective on the Role of Cognition ACT takes a very different view of cognition than is typical in the culture in general and in psychology specifically. The concern in ACT isn’t with the content of cognition. Rather, it’s with the ways in which cognition stands in for the world, accurately or inaccurately, and the ways it organizes behavior to diminish or make impossible valued living. In ACT, we call such instances fusion. Fusion is the process whereby certain verbal functions of events exert strong stimulus control over responding to the exclusion of other 54

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directly and indirectly available psychological functions. The reason this is limited to verbally established events is to distinguish the sort of narrowing of responding that might occur if someone were to say to you, “You are an incompetent therapist,” as opposed to the narrowing of responding we might see resulting from, say, a loud explosion. The former is made possible as result of verbal processes, whereas the loud explosion would likely narrow the repertoire of any creature capable of hearing—whether that creature were verbal or not. Mere awareness of that something, though frightening, is benign doesn’t seem sufficient. It’s entirely common for people with agoraphobia to know that their fears are overblown, for those with alcoholism to know they need to stop drinking, and for individuals struggling with depression to know they must get up and meet the day. In ACT, we foster interactions with thoughts that have the effect of broadening repertoires in their presence. In some ways, this work is analogous to exposure-based treatment. Let’s consider a specific phobia—say, fear of snakes. People with specific phobias make wonderful case studies in this area because, by definition, they have some awareness that their fears aren’t accurate. If a person has a snake phobia, we wouldn’t even consider trying to convince her that a nonvenomous snake is safe. Instead, what we do is have the person interact with snakes in a variety of ways, excluding avoidance. What results is that the person’s behavior becomes increasingly flexible in the presence of snakes. This core treatment strategy is among the most demonstratably effective in behavior therapy. It is ironic that when our clients’ repertoires are narrow and inflexible in the presence of snakes, we do exposure. When their repertoire is narrow and inflexible in the presence of heights, we do exposure. When their repertoire is narrow and inflexible in the presence of crowds of people, we do exposure. Yet, for some reason, a very different approach is traditional in cognitive therapy when a client’s repertoire becomes narrow and inflexible in the presence of a thought: I’m a loser, I’m unlovable, I’m a lousy therapist. We try to talk them—and even ourselves—out of the thought.

Is Fusion Bad? I know, I’m starting to bore you. However, if you already know the answer to the question “Is fusion bad?” I’m beginning to make my point. No. Fusion is not bad or good. Fusion simply is. In fact, there’s extraordinary adaptive advantage to fusion. When one early hominid said to the 55

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other, “Don’t go to the water hole, there’s a lion there,” if the other hominid responded to the word “lion” as if he was responding to an actual lion, he survived. Only one of these individuals actually saw the lion, but his words made the lion present for his friend. In the end, they both lived. It’s relatively simple to generate examples of fusion that are benign and sometimes even very helpful. For example, being deeply engaged with the words of a novel to the point where you lose awareness of things going on around you is good entertainment. If you’re about to step into a crosswalk and someone shouts, “Watch out for that car!” you might leap from the street in response to the words in the same way that you might respond to the actual car. Here fusion isn’t only benign, it’s also adaptive. There are many times, however, when fusion leads to behavior that’s directly contradictory to valued living. When the person with an alcohol addiction drinks in response to the thought I can’t stand these cravings, when the someone with agoraphobia stays home in response to I can’t stand another panic attack, or when a depressed individual stays in bed in response to I can’t face this day, opportunities to live a vital and engaged life are lost.

Fusion in Behavioral Terms There’s a long story and a short story to be told here. I’ll hint at the long (and technical) story and actually tell the short one. The short story is that fusion will very often involve aversives made present by verbal processes, and they’ll precipitate a narrow, inflexible, and relatively insensitive repertoire. In fact, many of the things we discussed as avoided events in the previous section on experiential avoidance are aversive as result of fusion. Consider the thought I’m a loser. No one will ever truly love me, and I’ll die alone. Such a stream of thought or even the hint of that thought might precipitate experiential avoidance on the part of a client (for example, drinking, avoiding dating, working sixteen-hour days). Looking through the fusion facet, we see that the client isn’t making contact with the fact of dying alone. How could he? He’s making contact with the thought of dying alone. Practicing acceptance of the thought might be one alternative way to interact with the thought, but ACT offers many. We might ask the client to say the thought rapidly over and over again. We might ask the client to close her eyes and imagine that the thought is like an object in front of her in space and then ask that she imagine giving it a color, a size, a 56

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shape, a temperature, and a texture. All of these exercises are aimed at reducing the dominance of the aversive functions of the thought while not necessarily changing the content of the thought. It’s part of the human condition that we create stories about ourselves and about the world around us. Our stories are often filled with limitations, and we proceed to live our lives inside those limitations. If clients have many things they can do in the presence of a thought or series of thoughts rather than only one thing, they are freer. And ACT is about freeing people from narrow patterns of activity that inhibit valued living.

Reflections on the Clinician As a therapist, if you want to understand this process in your own work, consider which thoughts show up for you as uninvited guests.

• I must do ACT well! • I don’t think I can help this client. • I can’t stand this client. • This client is sooooooo boring! Watch the way these thoughts organize your behavior. And while you’re doing what you do with those thoughts, what’s the client doing? How much awareness do you have of the patterning of his responding? What if you could learn to have your own thoughts as thoughts, and do what you value in that room? Would you be just a little freer in that room? Below, you’ll find an exercise to help you reflect on these questions.

EXERCISE: Reflections on Defusion Mull over or journal about the following questions:

• What thoughts often occur to you in the therapy room? • What is your client typically doing when these thoughts come up?

• What would it look like if you could have these thoughts and still do what you value in that room?

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SELF-AS-CONTEXT Questions of self in ACT are often focused on what might be called fusion with self-as-content. Self-as-content involves strong identification of oneself with prominent contents of consciousness, such as mood, thought, role, or bodily state. Self-as-context, by contrast, refers to the self that has experienced every thought, emotion, role, and bodily state you have experienced. This self is sometimes called the observer self or the transcendent self. Of course, there are many ways that we can understand self, including scientific views and spiritual views, among others. In order to understand self from an ACT perspective, one must understand a behavioral view of self. This view doesn’t preclude other views; it’s simply a way, not the way, to understand self. From a behavioral perspective, self is not a fixed entity (Hayes, 1984; Skinner, 1972). Self, or perhaps more properly “selfing,” is a particular stream of behavior. As such it is shaped in an ongoing and dynamic way by the context in which it exists. Early in life, children make mistakes in distinguishing their own perspective and that of others. Over time, they’re asked many, many questions about their own perspective and that of others. What did you have for breakfast? What did your brother have? Your sister wants ice cream. What do you want? Where were you this morning? What’s your favorite color? Through this series of questions, we learn to answer from a relatively consistent perspective. Like any behavioral pattern, however, it’s not entirely fixed. Different contexts can change what we see, feel, and think, and, importantly, even our sense of identity. Self is conceived as an ongoing stream of behavior that one is born in and as being dynamically shaped by that crucible of questions the answers to which begin with “I.” A narrow focus on difficult content has the potential to narrow the breadth of the experience of self. Consider, for example, an individual with psychosis presenting to a mental health professional. Almost certainly the three most consistent questions that the counselor or therapist will ask him will be have you been taking your medications, have you been having any side effects, and have you been having any symptoms (for example, hearing voices, thoughts of persecution, and so forth)? If I’m the individual with psychosis and my experience of myself is being shaped in a crucible of questions, what self is being shaped here? It’s worth asking ourselves if our focus on client difficulties contributes to a narrowing of the experience of self. Are we helping to

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perpetuate a subset of fused thoughts about self, where symptoms and roles of a mentally ill person stand in for the person as a whole? It’s problematic that the more distressed the client, the more likely we’ll find ourselves drawn to questions about distress. Problems are very salient and get our attention. (Remember the bear and the blueberries.) When our clients most need to cultivate flexibility, we ourselves are, ironically, most likely to become focused on distressing content—and we ourselves lose flexibility (in the form of therapist fusion and avoidance). In the chapters that follow, I’ll use experiential training methods to help you learn to cultivate a certain posture of equanimity with respect to Â�distressing client content. In doing so, we’ll embody the ACT principles we desire to cultivate in our clients. To the extent that we open up our clients’ distress (and our own!) and connect with it, we will be empowered to foster flexibility in our clients, helping them let go of distress and open up to other aspects of their experience. In order to discriminate a sense of self that’s distinct from the contents of consciousness, multiple exemplars are required. To the extent that our clients are engaged in a broad set of questions, in a slow and deliberate fashion, they’re more likely to notice the “I” that notices, the observer self. Focus on difficulties alone carries the risk of fostering fusion of self with difficulties (that is, I = depressed; I = anxious). In the service of noticing the transcendent sense of self, we bring our attention to bear in therapy on both sweet and sad moments. We move with flexibility and deliberate pacing among questions about values, vulnerabilities, and struggles.

What Causes Us to Lose Contact with Self-as-Context? The most prominent causes of loss of contact with self-as-context are fusion and avoidance. As I mentioned above, fusion with self-ascontent—excessive identification with certain emotions, memories, or roles—is generally the immediate cause of this loss of contact. Other forms of fusion will also generate a lack of awareness of self-as-context. For example, perceived threat or any event related to threat would be likely to precipitate such a loss of contact. This makes good sense, since fusion, especially with respect to aversives, has such a powerful connection to contingencies of survival. We must imagine that awareness of predators was much more valuable on the savanna than awareness of one’s sense of self as a unique and omnipresent perspective. 59

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Is Loss of Contact with Self-as-Context Bad? Here we go again. In this case, though, I think you’ll find that a loss of contact with self-as-context is generally benign. However, in the midst of a sea of aversives, contact with a sense of self that transcends all of those experiences, present and past, provides a life raft in an often stormy sea. Once again, it’s the degree to which this lack of contact interferes with valued living that makes it either adaptive or maladaptive to the individual experiencing it.

Self-as-Context (or Content) in Behavioral Terms My discussion of fusion in the section above also applies to fusion with self-as-content where the content is aversive: I’m the kind of person who can’t keep a job, I’m not the marrying type, People like me can’t go to graduate school, and so forth. Such content will have the same narrowing impact on behavior. The remedies within ACT will be the same: acceptance and defusion. In addition, “selfing” is itself a repertoire that’s in dynamic interaction with context. We can organize our interactions with our clients so as to cultivate broad and flexible patterns of “selfing.” We do so by asking many questions—sweet, sad, and mundane—that will grow that repertoire.

Reflections on the Clinician For the therapist, the same medicine applies. What are the stories you tell yourself about who you are and who you must be as you sit in that room? In what ways do those narrow your activity and sensitivity? Can you notice the you who notices all those repertoires—for good and ill? Can you act with kindness and flexibility when you encounter those limiting versions of you that come and go?

EXERCISE: Reflections on Self-as-Context Mull over or journal about the following questions:

• What stories do you tell yourself about who you are as you sit in the therapy room?

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• How do you think these stories might affect your clients? • What behaviors do you engage in to reinforce these stories or suppress them?

CONTACT WITH THE PRESENT MOMENT Contact with the present moment involves an individual’s capacity to bring attention to bear in a focused, deliberate, yet flexible fashion. Contact with the present moment, thus defined, is distinguishable from relatively rigid and fixed attention as might be seen, for example, in video-game play. While observing someone fixated on the screen of a first-person shooter, you might find considerable focus in the present moment but an extreme absence of flexibility. Contact with the present moment should also be distinguished from distractibility. Distractibility shows flexibility in attention to different stimulating events, both external (for example, sounds and sights) and internal (such as thoughts, emotions, and bodily sensations), but lacks the deliberate, focused quality we seek. The most striking case of the failure of present-moment contact is probably dissociation, where the environment around individuals has virtually no impact on them. Much more common presentations include worry and rumination. In worry, individuals lose contact with the present moment as they focus their attention on a conceptualized future. In rumination, the present is lost to a fixation on a conceptualized past. Note also that both of these also can be examined as instances of fusion—one with a verbally presented past and the other with a verbally presented future. Deep indulgence of either worry or rumination leaves individuals somewhat insensitive to moment-by-moment interactions with the world around them. Clinically, we might experience such an individual as preoccupied or detached—not quite there. Research suggests that worry and rumination are engines of sustained psychological difficulties (Nolen-Hoeksema 2000; McLaughlin, Borkovec, & Sibrava, 2007). Tom Borkovec’s pioneering work in generalized anxiety disorder (GAD) has shown that bringing individuals into the present moment by using relaxation exercises caused greater anxiety in subsequent exposure sessions and, importantly, greater benefit from those exposure sessions (Borkovec & Costello, 1993). In early accounts of the role of relaxation, the so-called relaxation response was thought to counter the anxiety 61

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response. Borkovec’s work suggests that it in fact facilitates anxious responding.

What Takes Us Out of the Present Moment? Often what takes us out of the present moment is some painful event. There’s a reciprocal relationship between contact with the present moment on the one hand and experiential avoidance and fusion on the other. Experiential avoidance and fusion have a very difficult time surviving in the present moment. For example, we can take even the most fused thought and get very present to it, to the bodily states that arise with the thought, to the inclinations to act that are associated with the thought, to the emotions that come with the thought. If we slow the interaction down and coach the client to express, moment by moment, each of these aspects of experience, if we ask the client to linger with each and breathe thoughts and emotions slowly in and out like air, fusion and avoidance tend to evaporate in the interaction. What emerges with painful events is a richer appreciation of the experience of life surrounding the event and a better capacity to respond to the painful event with sensitivity. The pain does not typically go away; it just ceases to dominate the client’s capacity to act.

Is Not Being Present Bad? Yes, it is. Of course I’m not being serious. As with all the other core-process breakdowns, you shouldn’t understand not being present as intrinsically bad or good. From an ACT perspective, things are only workable or unworkable in the context of a given value. It’s simple to point to examples when precisely the same act in different contexts might be quite workable or quite unworkable. Daydreaming involves a loss of contact with the events around us. On a spring day, lying out on a blanket in the warm sun, daydreaming might be a fine thing to do. However, the same act of daydreaming while driving could be disastrous.

Contact with the Present Moment in Behavioral Terms From a behavioral perspective, the value of being in contact with the present moment is easy to see. If you are to learn and be shaped by 62

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interactions with the environment, you need to be there to interact with it. This doesn’t merely mean that you must be there physically. You need to be psychologically present. If you have a fear of dogs or spiders, for example, you must interact with dogs or spiders in a variety of ways in order for their fearsomeness to recede for you. In nonclinical examples, sitting in the classroom daydreaming and looking at the clouds will not help you to learn algebra. To learn algebra, you must interact with formulae, numbers, and symbols of various sorts. Similarly, to interact effectively with the complex world around us— career, family, interpersonal relations, personal care—we must be teachable. The world can’t and won’t teach us what works unless we learn to pay attention. The capacity to bring attention to bear in a deliberate, focused, yet flexible way is thought to enhance learning of all sorts. The good news is that flexible, focused attending is behavior. It can be learned and enhanced through practice. The shaping of this capacity and the fostering of increased contact with the present moment is central to ACT.

Reflections on the Clinician Present-moment contact is every bit as important for you as a therapist as it is for your clients. You need to ask of yourself the same questions you ask of your clients. To the extent that you become excessively attached to a conceptualized future for your clients (“What if I can’t help them?”) or a conceptualized past (“I’ve done them no good at all”), you’ll be less available to interact with the small shifts in their behavior. In addition, to the extent that you’re worried and anxious and working hard to make these painful thoughts go away, your clients may begin to help you out by expressing less distress. This responsiveness on the part of your clients to your distress is not, in and of itself, problematic. If you’re invested in your clients’ pursuit of their values, you’ll likely feel sadness when they suffer a loss. Unless they’re in extraordinary and acute pain, it’s very likely that they’ll offer such help. The help they offer is likely organized by two streams of stimulus control. First, your pain is painful to them, and they may act to avoid it. However, they may also be acting out of kindness for you. If you yourself are able to bring flexible focused attention to bear in the present moment, you’ll be better able to interact with your clients in a way that honors their compassion without co-conspiring in their avoidance. Seeing both streams of stimulus control, you might offer, “I feel pain when you feel pain. I know that’s hard for you to see, but please 63

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know that I’m here by choice. I’m honored to walk in pain with you.” To see both values and avoidance simultaneously and to respond effectively will require you, in the room, to attend closely. Once again, here’s an exercise with some questions for you to consider.

EXERCISE: Reflections on Contact with the Present Moment Mull over or journal on the following questions:

• At what times do I tend to lose contact with the present in therapy sessions?

• How might these moments affect my clients? • What might it look like if I could remain in the room during these moments? How might my presence be of service to my clients?

VALUES Values are understood in many ways in different psychological, philosophical, and spiritual traditions. Values are, in an important sense, central to ACT. They direct and dignify the difficult work we do. As we move in the direction of our values, obstacles emerge. When these are obstacles in the world, we have our life task before us. When the obstacles are thoughts, emotions, and the like, we have a different sort of life task. From an ACT perspective, the task is openness, acceptance, and defusion in the service of movement in a valued direction.

Values in Behavioral Terms In ACT, values are freely chosen, verbally constructed consequences of€ongoing, dynamic, evolving patterns of activity,€which establish predominant reinforcers for that activity that€are intrinsic in engagement in the valued behavioral pattern itself. (Whew! We’ll look at the various 64

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aspects of this definition soon. Just hang tight.) Please, please note here that I’m not asserting that this definition exhausts what is meant by values in any global sense. Rather this is a way of understanding values as we use them in ACT.

VALUES ARE FREELY CHOSEN In ACT, values are not feelings. Although one may have very strong emotional responses in different valued domains, the two aren’t equivalent. Key to the distinction is that values are chosen patterns of activities that can be actively constructed by an individual. In some ways, the construction of values can be thought of like the construction of a house. Emotions are more like the weather where the house is built. Emotions often come and go. They may have patterns, but they aren’t chosen. Even thoughts often have this quality. If we attempt to actively have and not have certain thoughts, such purposeful manipulation has the potential to backfire. To use a specific example that illustrates the distinction between thought and emotion as values versus chosen patterns of activity, consider the area of racial prejudice. If you were raised in the United States (or many other places), you’ve likely grown up in a culture in which it’s more accurate to ask, “In what ways am I racist?” than to ask, “Am I racist?” Our culture (if you are American—perhaps even if you’re not) carries the baggage of racial oppression, and it takes a very long time for such things to change. Even when we personally value the practice of racial equality and abhor the idea of racial supremacy, we still carry some of the seeds of these prejudices. I think hard, as a teacher, about ways in which I can foster open dialogue about prejudice. I’m active in my consideration of the ways our department makes hiring decisions and the ways our doctoral program selects students. I construct learning activities that help reveal the ways that prejudices alter perception even outside our awareness. Yet I know that I’m not immune to these influences. Just because I’m susceptible to racist thoughts and feelings, though, doesn’t mean I can’t continue to chose the value of racial equality even when my thoughts and feelings don’t always cooperate. In fact, many, many of our most deeply held values are like this. Sometimes we feel very faithful to our roles as parents, spouses, or professionals. Sometimes we don’t. Sometimes we have very values-consistent thoughts about these activities. Sometimes we don’t. However, we may choose to pursue a valued direction regardless of these thoughts and Â�feelings. Part of the value very likely includes a certain steadfastness in the face of difficulties, both without and within. 65

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VALUES ARE VERBALLY CONSTRUCTED ACT is based on a post-Skinnerian behavioral theory that includes relational frame theory (RFT), a relatively new account of human language and cognition. According to RFT, relational or verbal conditioning processes are capable of making present psychological functions without the necessity of direct conditioning processes. Take as a case example Frankl’s experience in the death camps of Nazi Germany. One would be hard-pressed to generate a direct conditioning account of his act of staying in the camp. There were few, if any, reinforcers in the camp for Frankl’s decision to remain. Rather, his reinforcer was intrinsic in the match between his decision and his own verbal construction of what it meant to be both a doctor and a human being.

VALUES ESTABLISH REINFORCERS ACT is a contextual behavioral treatment, and as such the language of values is a special way to speak about reinforcement among verbally competent human subjects. As I expand and articulate a pattern of valued activity, I simultaneously establish reinforcers. For example, if part of being a father means spending high-quality time with my children, acts such as taking long family vacations, going to swim meets, and wandering the shopping mall become intrinsically reinforcing to the extent that they are part of the pattern. Reinforcers for nonhumans, with a few exceptions, consist of a relatively small set of evolutionary imperatives: primary reinforcers such as food, shelter, water, sex, and social contact for some species, as well as the events correlated with those imperatives, which we know as secondary reinforcers. Humans, by contrast, often value things that defy direct conditioning accounts: for example, reaching nirvana.

VALUES ARE ONGOING PATTERNS OF ACTIVITY In ACT, values are distinguished from goals. Goals are achievable ends. Values are patterns that can be abstracted from ongoing streams of complex human behavior. For example, getting a degree is a discrete, achievable end. Education might be a relevant value that could continue for a lifetime. ACT uses goals, as do many other behavioral interventions. However, in ACT goals are explicitly directed by client values. It is important to say that values are not so much discovered as constructed in the ACT model. Talk about “true” values or “real” values misses the mark. Using the house metaphor, we could imagine the house 66

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we would want to live in. We could plan it and begin its construction. We might make changes along the way. One day we might find ourselves living in a house that was quite comfortable, one that fit our lives. It would be odd to ask, “Is this my true house?” No. It’s the house you built. Do you like it? If not, what would you change? In the case of values, we ask, “What is the pattern I have made? How will I build it from here?” There is an active quality to such a line of questioning and one that is much less likely to lead to incessant second-guessing about the “truth” of one’s values.

VALUES ARE DYNAMIC AND EVOLVING Values in ACT are evolving patterns of activity. Consider parenting, for example: the pattern of activity that defined being a good dad to my daughter at two years of age is different than being a good dad when she is thirty-two. The primary reinforcer is intrinsic to the act itself. Frankl’s story is an apt example of such a pattern of activity. The predominant reinforcer described by Frankl is to be found in the consistency of his actions with his ongoing construction of what it meant to be a doctor and, more broadly, a person. Because we’re talking about reinforcement, the behavior of interest is what we call operant behavior—that is, behavior that’s sensitive to both antecedents and consequences. We should be aware, though, that there’s an intimacy between values and vulnerabilities. As described earlier, values and vulnerabilities are always poured from the same vessel. When we’re working on values with clients, there’s also a high likelihood that related vulnerabilities will surface. This is especially likely where clients have had losses or personal failures in their history. For example, if someone has a history of behaving poorly as a parent, talking about that value is as likely to generate aversive control with all its repertoire-narrowing effects as it is to generate positive life change. To the extent that the person deeply values parenting, the potential for fusion and avoidance is increased. If the person didn’t value parenting, the domain would be a matter of indifference. A conversation about parenting would be unlikely to generate motivation, but it also wouldn’t produce fusion and avoidance.

Reflections on the Clinician In order to understand the double-edged qualities of the facet of values, it’s worthwhile to examine the ways these matters play out in 67

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your clinical work. What is it that you value in the work that you do? Or, said another way, who would you like to be in the lives of your clients? At workshops, I sometimes ask people to imagine that they’re at the “therapist buffet.” I then describe the dishes available to them: here we have lousy therapist, then okay therapist, which is followed by pretty good therapist, and in this last dish, we have amazing therapist. Which would you like? Remember, this is a buffet. You can have any one you want. Sometimes I ask people to say out loud what they want. Imagine what this would be like for you—to say out loud in a room full of therapists what kind of therapist you want to be. Imagine I ask you to look around the room, into the eyes of your peers, and then to say to them, “I want to be an amazing therapist.” Imagine saying it loud enough to be heard clearly and unambiguously. Imagine owning whatever comes up. What do you feel? Can you feel a bit of constriction? A bit of reluctance? A bit of hesitation? And let me ask the same thing of you right now: What if it were possible for you to be an instrument of extraordinary change? What if you could be an instrument of liberation in the lives of your clients? See if you can feel the push and pull that arises when you consider claiming that possibility. As is often the case, poets express these kinds of tensions in ways that behaviorists and psychologists might not: Do I dare Disturb the universe? In a minute there is time For decisions and revisions which a minute will reverse. For I have known them all already, known them all— Have known the evenings, mornings, afternoons, I have measured out my life with coffee spoons; I know the voices dying with a dying fall Beneath the music from a farther room. So how should I presume? —T. S. Eliot, “The Love Song of J. Alfred Prufrock” (1991, 4–5) Why do Eliot’s words ring so true over so many years and in so many lives? And you, do you know something about measuring life out with coffee spoons? Do you dare? Do you dare? If you can let yourself know that hesitation, that small tremor, and meet it with equanimity, and breathe it in and out like air, and welcome it with acceptance and kindness, you might know something of the push and pull your clients feel around their values. 68

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This next exercise is a monster. Don’t feel like you have to come up with the “right” answers. Remember that values are ongoing patterns of activity. I hope, though, that you’ll take the time to sit with these questions.

EXERCISE: Reflections on Values Mull over or journal on the following questions:

• What matters to me as a therapist? • What comes up for me as I write down those words, as I claim this possibility?

• What might it mean both to me and to my clients if I could act to further this value?

COMMITTED ACTION The last of our facets is committed action. “Commitment” in common usage is often almost synonymous with a promise made with reference to the future. While making such a promise might be part of a commitment, such a promise in no way exhausts what is meant by commitment in ACT. If we were always moving in a direction that was consistent with our values, committed action would be synonymous with values. However, committed action emphasizes the ongoing choosing and rechoosing of a direction. Committed action, in flight, can be seen metaphorically in a breathing meditation. In such practice, we choose our breath as a place to bring attention to bear. Of course, what we find is that our attention wanders. We begin to think of activities that we need to do later, or perhaps different pains and discomforts capture our attention. When we notice this, we may linger a moment. We meet our inattention with equanimity, like meeting an old friend on the road. “Hello,” we say. We let go of our inattention and gently return to our breath. I believe that the heart of commitment lives in that gentle return.

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Consider a value like parenting. We choose parenting as a value and evolve a pattern of activity consistent with our value. Some days, some moments, we will be well oriented within that pattern. Other days, other moments, we’ll find ourselves at odds with our value. In that moment, the moment in which we notice that we’re out of alignment with our value, can we pause, notice our dislocation, and gently return? It’s difficult to imagine a value of any magnitude that will not involve a lifetime of gentle returns. Theoretically, committed action isn’t terribly distinct from values. If you consider some valued domain—such as parenting, career, being a brother or sister—making and keeping commitments is likely part of the pattern. In this sense, commitment can be viewed as part of valuing. From a practical perspective, though, there will be times when there’s great advantage to keeping commitment separated from values, if only temporarily and strategically. For example, when working with clients who have values that they have long neglected or have violated in important ways, fusion and avoidance are likely to be quite high. Consider the client with a substance abuse problem who has a history in which she’s neglected or even endangered her children. The client may have a story about how bad she is as a person and may be very attached to that story. She may also avoid any activity that brings her into psychological contact with parenting because such contact is terribly painful. For such a client, sometimes a line of inquiry that takes commitment explicitly off the table can be very fruitful. As a therapist, I’ve often been successful asking a client to help me to see in a very visceral way what he values in some domain without any commitment to Â�do Â�anything. Sometimes doing present-moment-focused acceptance and defusion work around a value can lessen fusion and avoidance enough to make some small commitments possible. We’ll explore different ways to structure interventions in a later chapter. For now, just consider this subtle Â�distinction between committed action and values.

Committed Action from a Behavioral Perspective As mentioned above, committed action is in some ways not theoretically distinct from values. Part of the valued pattern is a persistent return to the pattern when one strays. If done in the context of acceptance and defusion, return to the pattern will itself be intrinsically reinforcing. 70

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Reflections on the Clinician If being an instrument of change for your clients is a value you have, you need look no further than that value and your interactions in the therapy room to see opportunities for commitment in action. How many times during a session have you found your own attention drifting to matters other than the client? How many times have you found yourself in therapy treating your client as if she were a problem to be solved? Can you notice, in those moments, your values speaking to you? If you accept their invitation and make that gentle return to your client and to your value, you’ll know something of commitment. I invite you to linger a moment in your next session over that moment on the cusp of return. See if you can notice the intrinsic vitality of that return. Or, conversely, if that is obscured, notice fusion that stands reprimanding you for having to return again. And gently breathe that reprimand in and out like air, make your return, and notice the shift in your own presence.

EXERCISE: Reflections on Committed Action Mull over or journal on the following questions:

• What

kinds of actions are you committed to in therapy sessions?

• When

do you notice yourself turning away from these commitments?

• Can you gently return to them? What does that look like for you?

MINDFULNESS AND ITS RELATION TO THE HEXAFLEX I’ll take Jon Kabat-Zinn’s definition of mindfulness as a starting point. Jon suggests that mindfulness involves “paying attention in a particular way: on purpose, in the present moment, nonjudgmentally” (1994, 4). From an ACT perspective, I believe that mindfulness can be usefully 71

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understood as the convergence of the four processes on the left side of the hexaflex: contact with the present moment, acceptance, defusion, and self-as-context. The most obvious ACT connection to mindfulness is to be found in the here-and-now quality of mindfulness itself. We bring attention to bear in a flexible and focused way to some selected object of attention in the present moment. The focus component suggests the intentionality of the individual who is being mindful—as Jon says, “on purpose.” Being mindful of our breath, for example, is chosen. Each time our attention drifts or is captured by something before or later, we return to our breath in that very moment. The nonjudgmental posture of mindfulness is captured by the acceptance dimension of ACT. In being mindful, many things arise. All are met with openness. We bear witness with acceptance: to thoughts, emotions, memories, urges, and, paradoxically, even to the judgments that will surely arise.

The ACT Hexaflex Model Showing the Mindfulness Convergence

In coaching an accepting and open awareness of thoughts as thoughts, of emotional reactions as emotional reactions, of sensations as 72

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sensations, we notice these things as ongoing processes rather than being caught by the contents of consciousness. This is an example of defusion. Thoughts, emotions, and the like continue to arise; however, they stop organizing behavior in any strong sense. When a client returns again and again to the present moment, witnessing with equanimity each thing that arises in awareness, he also makes contact with a sense of himself that’s distinct from the contents of consciousness: the observing self or self-as-context. He may contact self-as-context not just conceptually but also experientially.

Mindfulness and Defusion or Exposure In a certain sense, mindfulness is, in and of itself, a defusion strategy. However, it can also be used in conjunction with a variety of other defusion strategies. For example, a couple minutes of mindful attention to the breath can better equip clients to engage more fully in some of the more classic ACT exercises, such as the Physicalizing Exercise or the Tin Can Monster Exercise (Hayes, Strosahl, & Wilson, 1999). (These will probably be familiar to you if you’re not very new to ACT. If you are, please take a look at the Recommended Reading section at the end of this volume.) Thoughts can be particularly difficult to notice without getting hooked. Coaching focus on physical sensations—like focusing on the minutiae of sounds or tactile sensations such as temperature or physical pressure (for example, the sensation of your clothes where they touch your body) or focus on breath—is somewhat simpler. Beginning with these simpler mindfulness exercises before moving to trickier areas like thoughts is likely to make mindful observation of thoughts in exercises like Leaves on a Stream or on Placards in a Parade (Hayes et al., 1999) more readily accomplished.

Mindfulness and Acceptance As with defusion, mindfulness is, in some senses, intrinsically an act of acceptance. However, when a client has particular psychological content that generates a narrow and inflexible repertoire, coaching acceptance in a mindful state can be much more effective than coaching acceptance without mindfulness. As a general rule, it’s worth including even a brief mindful moment before asking a willingness or acceptance question. I find that this comes fairly naturally to me in that when I’m 73

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asking willingness and acceptance questions, I ask them at a point where I’ve allowed the magnitude of the question to sink in for myself. If I’ve encouraged the client to help me feel the grit and grain of her struggle, feel the cost of it, feel the terror of letting go, I’ll pause before asking just as I’d pause a moment before jumping from a cliff (it may well feel that way for clients). I don’t want to rush these questions, so I pause and let all that ambivalence and longing fill in around us. I grow quiet. Then…I ask my acceptance question.

Mindfulness and Contact with the Present Moment Mindfulness is one of our most direct interventions to precipitate being in the present moment. It also provides a teaching opportunity. Having precipitated the experience of being in the present moment, it’s worth using the moments that follow as an opportunity for discrimination training. When we’re very stuck in therapy, learning to discriminate the difference between being in the present moment and not being there can allow us to notice whether we’re present-moment focused or not. I tend to be less interested in the logical distinction than in the experienced distinction. Metaphorically, what I’m after here is that clients will be able to say, “Hey, that was green, wasn’t it?!” rather than to say, “Green is the result of combining blue and yellow.” I recall a fellow in a clinical trial years ago who understood Zen inside out but spent zero time in the here and now.

Mindfulness and Self-as-Context As with being in the present moment, mindfulness can be a powerful way of precipitating the experience of a sense of self that’s independent of the contents of consciousness. It’s worthwhile in extended mindfulness exercises to occasionally ask your client, “As you notice your breath, notice who’s noticing that!” The Observer Exercise from the original ACT book (Hayes et al., 1999) is a good example of how to use mindful noticing in order to precipitate a strong sense of self-as-context. Just by following such an exercise, we may also find that it’s possible to reinforce a therapeutic contract. Making an agreement with a client about the purpose and direction of treatment right after doing such an exercise will likely facilitate making an agreement with the person rather than the person’s story about himself. 74

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Mindfulness, Values, and Commitment Once again, a poet captures in a few lines what the psychologist writes a book about: He who binds to himself a joy Does the winged life destroy; But he who kisses the joy as it flies Lives in Eternity’s sunrise. —William Blake, “Eternity” (1976, 135) Values can provide a good focus within a mindfulness exercise. Sometimes values provide such a goad to action, such a sense that we must act, that we can lose appreciation for that which we value. For example, sometimes our lives with our children become a rush from one responsibility to the next. Occasionally, however, we happen upon moments of pure appreciation. There are times when my youngest daughters are playing together, just the two of them, without an ounce of self-consciousness, no awareness that they’re being watched. In these moments, I have a deep, deep sense of appreciation for the richness of my life. Sometimes in the midst of a mindfulness exercise where, by definition, you’re engaged in appreciation rather than action, this rich sense of values can emerge. Commitments to valued directions sometimes emerge more readily as fully present, voluntary acts when made on the heels of experiencing such mindful, in-the-moment appreciation of a relevant value.

THE PRESENT MOMENT AS ANTIDOTE FOR NONACCEPTANCE AND FUSION In the ACT model, we believe that a great deal of human suffering is generated by fusion and avoidance. As time goes by, I’ve become increasingly convinced that fusion and avoidance have a very, very hard time surviving the present moment. Even when a client is too agitated, worried, or angry to make a formal mindfulness exercise practicable, sometimes just slowing the client down—persistently, over and over again—can settle her into the present moment. And with that presence, some degree of acceptance and defusion often follow. We find ourselves there, in the 75

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room, with the client well met. That’s a place where possibilities are born. We can give birth to that place in our moment-to-moment interactions with our clients. Before we discuss the means by which we can learn to infuse our conversations with mindfulness, we’ll examine some technical aspects of mindfulness in chapter 4. These aspects will be useful both in formal mindfulness exercises, and, more central to this book, in the exercise of a particular kind of conversation I call “mindfulness for two.”

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Chapter 4

Integrating Mindfulness Work into ACT

Problems get hold of us from the moment we arise in the morning. What will I eat? What time is it? When do I need to leave for work? What will my first task be upon arriving there? What projects need finishing? What meetings do I need to attend? Do I need to pick the kids up after work? Are there piano lessons or soccer practice? Do I need to stop for groceries? What will I make for dinner? Problem solving is our most prevalent mode of being. It’s no coincidence that literature is filled with exhortations of carpe diem. We very often seem to be carried without much awareness from one task to the next. And at what cost, this inattention? Even figured against the events of our workaday lives—picking up the kids, doing the filing, raking the leaves—mindlessness can be quite dear. So what might the cost be of a lack of focused, present attention during that rare hour each week we spend with a client? What details might go unnoticed? What Â�unproductive habits might be reinforced? What Â�opportunities might slip away? In this chapter, we’ll explore the ways in which mindfulness and its lack can help and hinder the course of an ACT intervention. We’ll examine technical aspects of mindfulness. I’ll also provide some working scripts you can use to facilitate and coach mindfulness. My hope, though, is that these technical notes will help you develop the sensitivity and facility to construct your own exercises and mindful moments to Â�generally facilitate mindfulness for two.

Mindfulness for Two

MINDFULNESS, MINDLESSNESS, ORDINARY CONVERSATIONS, AND ORDINARY LIFE Sometimes life conspires to wake us from our sleep. Death of a Salesman is a classic literary study that considers the possible endpoint of a life filled with one task butted up against the next. The life of Willy Loman, the salesman in the story, ends tragically. Willy’s son, Biff, speaks to his father as if to rouse him: Willy! I ran down eleven flights with a pen in my hand today. And suddenly I stopped, do you hear me? And in the middle of that office building, do you hear this? I stopped in the middle of that building and I saw—the sky. I saw the things that I love in this world. I saw the work and the food and the time to sit and smoke. And, I looked at that pen and I said to myself, what the hell am I grabbing this for? Why am I trying to become what I don’t want to be? What am I doing in an office making a contemptuous, begging fool of myself, when all I want is out there waiting for me the minute I say I know who I am! Why can’t I just say that, Willie? (Miller, 1967, 128) Is Biff alone in this? Biff finds himself living a life disconnected from his values. But even when we’re doing things that are consistent with our values, we’re prone to lose a sense of appreciation for those values. How often do work, marriage, and parenting occur for us as burdens? Disconnection from values and from life is available at each and every moment. This is certainly true walking into a session. We, along with our clients, are carried into session by the pace of our day. The rapid succession of tasks and the often-frenzied pace at which we engage with them can easily determine the tempo of our interactions with our clients— often to both their detriment and ours. Mindfulness is a great way to start a session. It’s a way to take intentional control of the pace and pitch of life—at least during this time we have set aside for our work. We want to ensure that we have the pace rather than the pace having us. Moments of mindfulness are likewise usefully interspersed in a session. A bit of mindfulness will slow us down and slow our clients down. No matter what activity we plan for a session, there’s little doubt that focused, present attention—on both our part and our clients’—will be an asset. Coming into a session we’re often busy. We may be thinking about the last client, about the client we’re about to see, about the contents of 78

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our last session with this client. Our minds fast-forward to what we might accomplish with this session, about a colleague we need to speak to, about some administrative detail, and so forth. Similarly, our clients may be trying to remember what they did during last session. They may be worrying about whether they did their session homework or even trying to remember what those assignments were. They may still be caught in the hustle and bustle of breaking away from some activity to come and meet with us. However you look at it, there is abundant opportunity for inattention and distraction offered up to our clients and to us before the start of each session. Mindfulness is a way to disrupt these patterns of distraction and bring us rapidly into the here and now.

WHAT WAS THAT? Do you remember what I wrote in the prolegomenon, about what led me to an interest in mindfulness in the first place? It was that I had a very hard time listening carefully to my clients. Whether in conversations with a client or in everyday social exchanges, all of us have had at least some trouble with listening. This difficulty is in large part due to the fact that, without active and focused attention, we can literally miss half or more of what people say to us in a conversation. We want folks to follow our vocal instructions, so we need to do things that keep people from spacing out and going off on little head journeys while we’re speaking to them. In ordinary conversation, we can listen to about half of what people say and get by pretty well. Watch yourself while you’re conversing with someone, and notice that you can often anticipate what’s coming. Notice that you don’t listen to every word. Notice also that while you’re not listening, you’re somewhere else—planning, pondering, or thinking, perhaps, but somewhere else and often somewhen else. The same is true of others. (Or maybe this is just me—yipes! Is it just me? Heavens! I hope it isn’t just me! You know what I mean, don’t you?) Try this experiment: When speaking casually to another person, just toss random words into your sentences. Don’t change inflection or pace; just drop them in like they belong there. People will often hear what fits and not necessarily what you said. Likewise, people see what fits. Here’s a visual example: Paris in the the spring 79

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Right now, go to the bottom of this page and read the footnote.1

PLACEMENT OF MINDFULNESS IN A SESSION Since our sessions are essentially hour-long conversations, you can easily see how much opportunity might be lost if half or more of the conversation in the room goes unnoticed. Integrating mindfulness into the session is one of the best antidotes to this disconnected situation. But how and where should you begin to introduce mindfulness into your work? As I suggested above, dropping a small bit of mindfulness in at the beginning of a session is a great idea. A brief mindfulness exercise prior to experientially challenging exposure work is likely to facilitate greater engagement with the distressing object or situation. Even two or three minutes devoted to simply noticing the inflow and outflow of breath can make an important difference. Tom Borkovec’s work has been very suggestive in this regard. Tom has found that a bit of progressive muscle relaxation prior to an exposure session causes the exposure to produce better outcomes (Hazlett-Stevens & Borkovec, 2001). This makes sense when you consider basic learning processes. We learn better when we’re present than when we’re absent, distracted, or preoccupied. Humans are great at being physically present but psychologically absent (several of my students have mentioned my capacity for this). Exposure sessions are, like virtually all of the work we do in therapy, opportunities to learn new behaviors. In particular, they are opportunities to learn how to respond to distressing stimuli in new and, we hope, more adaptive ways. The presence that the initial mindfulness work fosters makes the goal of learning these new behaviors more easily attainable. Another very good place for a mindful moment is when we find ourselves or our clients working very hard. As a general rule, when you find yourself in conflict, struggling, or exerting a lot of effort, a mindful moment can help. Things capture our attention. Things we call “Â�problems” really capture our attention. Again, there are likely very good evolutionary reasons for this: we remember very well from our days wandering the savanna that it’s better to miss lunch than to be lunch. 1 Without looking back, immediately write the words you just read below. Then go to the footnote at the bottom of the last page in this chapter (page 96). 80

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The problem with problems, though, is that they become merely problems. It’s the “mereliness” of our problems and struggles that damns us. Our problems often insist that they must be dealt with right this moment! And this insistence can cause us to lose all sense of everything else that surrounds us. Such a sense of struggle and effort while sitting in a chair is a sure sign that your mind is trying to keep you from being eaten. When either you or your client gets into this situation, look carefully around the room. If you don’t see any bears, it’s probably safe and useful to stop for a mindful moment. Just let the silence fill in around you and encourage your client to do the same. Sometimes the most surprising things will show up in those moments. I originally started doing this pretty naturally. I wasn’t really thinking in terms of mindfulness. I was just stuck and confused, and I somehow learned to shut up, sit still, and cease any effort when I didn’t know what else to do. I learned to wait. I learned to practice acceptance. I learned to let my thoughts run on ahead. I promised them that I would catch up later (but really I was just shining them on). As I write this, I feel a tug inside that wants me to write you a list of complicated-Â�sounding instructions about how to do this. But the truth is that I got there by just sitting still for a while and giving my mind permission to take a short holiday. It sounds almost too easy, and it can be. But remember that, in the context of a mindful moment, just sitting still can and should be done quite intentionally and explicitly. Try it in your practice—either in your consultation group or with a client. When you notice yourself getting busy, ask the client if you can take just a moment to settle. Let the room grow still for a couple minutes. Get present to something, anything in the current environment—sound, temperature, muscle tension, or your breath. When you find your attention coming back to the problem you’re struggling with, notice that, and return gently to whatever it is that you’re focused on. Take a moment. Let the world fill in around you. And then, having settled, come gently back to the task. I’m often asked about correct placement of these mindful moments. Really, it’s difficult to go wrong. Human avoidance is so ubiquitous that stopping humans at just about any given moment will mean stopping them when they’re running. I sometimes joke at workshops that I have a fail-safe detector that can tell me whether a person is in need of a mindful moment. I then feel the person’s wrist. If I can detect a pulse, the answer is yes. If you really want to get a direct sense of the ubiquity and automaticity of human problem solving, try what is suggested in the previous paragraph. You can even try it all by yourself. I’ll even make it formal in an exercise. 81

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EXERCISE: Just Sit Still Simply stop reading at the end of this paragraph. Go find something that you can use to keep time for three minutes. Start the timer, and let your awareness come to rest on your breath. Let go of any problem solving until the timer goes off. See what happens.

If you found yourself getting busy, welcome to the human race. Minds hate unemployment. If there’s nothing to do, they’re happy to generate make-work projects. And they don’t ask our permission when they do it.

QUALITIES OF MINDFULNESS EXERCISES AND MINDFUL MOMENTS So what qualities should you look for in your mindfulness exercises and mindful moments? What states should you foster in your role as a therapist? A thorough list would be long indeed. And we could talk about these qualities as either in the room—a positive indication of contact with the present moment—or not in the room, which would suggest a lack of present-moment contact. Since the next two chapters are devoted to recognizing breakdowns in present-moment contact during therapy sessions on either your part or the part of your clients, let’s spend some time focusing just on the positive indicators of engagement with the here and now. Again, there are a number of things we might choose to look for: body language, eye contact, interactions with pens, watches, or objects close to hand. But they call it “talk therapy,” right? Most of what we do in the room is talking, so it seems as if the spoken word might be a good place to look for evidence of mindfulness during our sessions. And for our purposes here, let’s focus on two aspects of our talking, namely our voices and the content of what we have to say.

Voice Your voice is a powerful instrument in your sessions and can be used to dramatically alter the quality of what you get done in them. You might think of your voice as the pipe through which your education, clinical 82

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experience, insight, and intuition flow to your client. No matter how deep your understanding or keen your therapeutic instincts, if the pipe is clogged, nothing gets through. If it’s too wide, the stream of what you have to say will flow out too fast and won’t be well absorbed. If the pipe twists and turns and doubles back on itself—well, let’s not stretch the metaphor too far, but you get the idea. Learning to use your voice well will give you the best chance of bringing your hard-earned clinical prowess to the fore in the service of your client. I’ll break this discussion of voice into three parts: tone and pitch, pacing, and the use of tempo and pauses.

TONE AND PITCH I like to begin mindfulness work speaking in a soft, steady, deliberate voice—something that’s in the middle of my normal speaking pitch. This matters because it gives me someplace to go pitch-wise as I proceed with the work, varying my pitch in order to put emphasis on something in particular. For example, I might ask a client doing a mindfulness exercise to notice the temperature of his hands. Begin to notice the temperature of your hands [pause and notice]. See if you can notice that there is slight variation in that temperature [pause and notice]. See if you can notice that one hand is just slightly [with voice just a bit higher and a bit softer, like you’re telling a secret] warmer than the other hand [pause and notice]. See if you can find the warmest place on your hand. See if you can notice any tiny sensations that go along with that warmth [with voice a bit higher and softer—and then pause and notice]. See if you can notice that, right—at—this—very—moment [said with just a bit more force—and then pause and notice]. Can you see how this works? It might be hard to grasp from the printed page, which is one of the reasons we included the video sessions with this book. Listening to my formal mindfulness inductions on those recordings will give you a better idea of how you might use variations in pitch and tone to facilitate great mindful presence with a client. In general, these variations in tone on a backdrop of slow, soft, steady speech will continuously draw your client back to the exercise and into the present moment.

PACING In short, go slow. How slow? My own guide is to pace mindfulness exercises by actually following my own instruction. In the time it takes 83

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me to do what I’m asking my clients or trainees to do, I can usually assume that they, too, have had a chance to fully absorb the direction. I typically have clients do mindfulness exercises with their eyes closed, and I usually close my eyes while I’m guiding them. I may let my eyes drift open gently and then allow them to drift back closed, but I generally keep them shut. Letting go of our dominant sense lends deliberateness to what we’re doing, and this tends to slow things down, in my experience. If I try to guide an eyes-closed exercise with my eyes open, I find that I’m sort of set on a faster speed than my client. Following the instruction I give tends to keep me operating at the same speed as the rest of the room, whether it consists of one client, a practice group, or a whole workshop. You find useful material for guiding a mindfulness exercise in your own engagement with the directions you’re giving. If I say something like “Stop for a moment and notice your hands,” I will then stop myself and carefully notice various sensations in my hands. When I do, I often notice different temperature sensations on my fingertips, my palms, one my pulse points, and so forth. When I do, I might say, “See if you can notice that there are small variations in temperature on different places on your hands.” I would then spend another moment noticing that myself. I might then feel a tingle in my right ring finger, whereupon I might say, “See if you notice tiny tingling sensations.” Then I shut up and try to notice any little tingles. Sound like cheating, doesn’t it? But this is really what you’re trying to foster with these exercises: conscious, nonjudgmental attention to things as they are in the here and now. My typical instruction pattern looks something like this:

• Notice • Speak • Then notice again, just a bit more mindfully • Then speak • Then notice • Speak again • Notice one more time When I do this, I find that my pace works better for the clients than if I think explicitly about how long to wait between instructions. I also find that if my instructions come out of my experience, my pacing improves. 84

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The goal of mindfulness practice is to connect to your present-moment experience, and this is ultimately what should inform your work. Even if you use scripts from this book for your meditations, use them just as guides. Read the meditation and get a sense of the general shape of it. Then try doing the meditation. When you go on to use the mediations with your clients, though, keep with the spirit of the thing by remembering to infuse it with your own experience of the moment.

VARYING PACE, TONE, AND PITCH While a slow and steady pace is the backdrop for a mindfulness exercise, variations on that backdrop will serve to draw the client’s attention back to your voice and to the next bit of guidance. Both the soft, slow, steady backdrop and the variations are important. It’s the slow pacing that gives depth to moments where the pace speeds up just a bit. It’s the soft backdrop that brings into relief the places where particular words are given a bit more emphasis.

PAUSES AND TEMPO A slow, deliberate pace makes an excellent backdrop for intentional alterations of pacing. Think of this auditory backdrop as a primed canvas or the bass line in a song. It’s an anchor, a place to start from, a context in which action can occur. It provides a backdrop that gives relief to the variations we introduce. The more consistent the backbeat, the more clearly we note the variations. We need this because in our daily conversations our attention drifts in and out, and the unexpected changes draw our attention back to what’s being said. When drifting has a cost, as it does when we lose the thread of the conversation, we either work hard to catch up or say something such as “Excuse me, could you say that again?” You can short-circuit the habit of half listening by building in some variation on a backdrop of slow, deliberate pacing. Variability in tempo is a good strategy. I will often put———pauses in———where they don’t———belong. This is a sort of antipunctuation. Don’t build the pauses in where periods and commas would go. In fact, they’re more effective dropped in places that would ordinarily flow together. If you overdo this, you’ll annoy people. But a bit of unexpected pausing helps to maintain attention. Try this in ordinary conversation. Start to speak and then——— pause———in mid———sentence and watch the person you’re speaking to attend more closely. Let your pauses draw out a bit. Throw in a 85

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few. The listener will hang on to the next word. I live in the South and have heard some extraordinary African-American preachers. These folks understand the potency of a well-placed pause. Listen to your favorite music and notice how the pauses draw you forward into the next phrase in the music. The rests in a piece of music are as important as the notes. If you doubt this, I invite you to listen to one of those computerized greeting cards for half an hour—the ones that play “Happy Birthday” or “Jingle Bells” in a piercing, computerized loop that’s all continuous music, with no rests or respites. If you do, I suspect you’ll agree with me that the pauses between the notes add much-needed interest to the sound. How long should you pause? It depends. When I’m guiding a mindfulness exercise, I’m not in my head counting, “Okay, elephant 1, elephant 2, elephant 3—that’s long enough.” As for the general pacing of speech, I measure the length of pauses by becoming a listener to my own words. I hang a bit on my next word, listening for it for a moment. When I can feel a bit of anticipation, I pause just a bit longer and then let the next word drop. I hold these pauses as long as I can comfortably tolerate—and then I hold them just a little longer. I notice my urge to move ahead. I will often comment on this urge: “See if you can notice yourself trying to move ahead in the exercise.” Then I pause and notice myself longing to push forward. Once again, the time I take to notice these impulses to rush ahead will probably give my clients or trainees enough time to do the same thing. Our natural inclination is most always to move more quickly than is useful. As a general rule, slow down just a little more than you think is enough. A parallel concept to the pause in the spoken word is negative space in the visual arts. Negative space is that space on the canvas or in the sculpture that has nothing in it. Balancing positive and negative space and playing with the two creates interest and draws attention. Novice artists pay too much attention to positive space (the subject) and not enough to negative space. Just as an example, in da Vinci’s painting The Last Supper, the subjects are bunched together with the exception of the space just to the right of Jesus. That small difference in spacing has attracted enormous attention and speculation about the meaning of the space. Whether or not you think there is any substance for the claimed symbolism of the space, it is unquestionable that it has drawn extraordinary attention. Consider the idea of negative space as you construct mindfulness exercises and briefer mindful moments. A fairly organic way to Â�introduce

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this into your mindfulness work is to take some time to appreciate negative space. Do mindfulness exercises with no one at all in the room. Instruct your own attention to come to rest on something like your breath. As you do so, introduce pauses into your speech and then linger a moment over those pauses. Become interested in them. Attend to them. Listen to them as if they had a secret they could tell you and then see what happens. One thing that’s likely to happen is that your mind won’t like the exercise. That is fine, and expected. Just persist and attend to that negative space you’re creating.

Practice, Practice, Practice In order to learn more about tone, tempo, and pauses, do mindfulness exercises with your clients or practice group, or even by yourself. If you’re feeling very ambitious, record a few of your exercises and then listen to them several times. Pay special attention to the qualities of your voice and especially to those pauses. This sort of practice will improve the aesthetics and fluency with which you use your voice, as well as that space between your words, and a more fluent voice will mean a more powerful and direct delivery of your clinical abilities to your clients.

THE CONTENT OF MINDFULNESS The content of a mindfulness exercise can vary widely. Just look around at the various schools and practices in the traditions from which mindfulness emerged: mantras, breathing, walking, sweeping, playing the flute with a basket on your head—the list goes on. What this suggests is that mindfulness can be effectively and usefully applied to a wide variety of content. That said, some domains are easier to be mindful in than others. I’ve always found that becoming mindful of thoughts is the trickiest of tasks. Just noticing yourself thinking a thought is hard (at least for a monkey mind like mine). In fact, most exercises that involve noticing thoughts, like Leaves Floating on a Stream from the first ACT book (Hayes et al., 1999), are used to show to what extent thoughts pull us in. By contrast, it’s far easier to focus attention on a spot on the wall, on one of the small sounds in the room, or on the breath.

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From Prominent to Minute As a general strategy, moving from very prominent foci to subtler, more specific, and detailed ones can serve to refine our attention and to draw it into the present moment. Generally speaking, “things” as we notice them are aggregations of still smaller “things.” If we pay close attention to larger and more complex (and thus more prominent) phenomena, we’re likely to notice the smaller details that make them up. A good example would be to notice the sounds in the therapy room. As part of a mindfulness exercise, you might ask clients to imagine that they have a mental checklist. Ask your clients to start with the most prominent sound they can hear—maybe the buzz of an electric fan or the traffic on the street outside—and check that one off. Then ask them to listen for something slightly less prominent, some sound within the sounds of the room—the rustling leaves of a plant on which the fan is blowing, the unique sound of tires on wet pavement outside—and check that off too. Have them repeat this refinement until they’re listening to the tiniest sound perceptible—perhaps the soft thrumming of their own pulse. Or you can ask your clients to focus their attention on one prominent sound, like the heating or air conditioning. As they begin to focus, ask them to notice that, within that sound, there are variations—softer or louder sounds, higher or lower pitches, cycling from softer sounds to louder ones, from higher pitches to lower ones. With attention, it’s possible to discriminate a great deal of detail within what might otherwise just be called white noise. The focus on different sensory aspects of the breath is perhaps the most common meditative practice, in large part because the breath is readily available. The breath contains a nice variety of sensory details that can be used to draw a person into the present moment. From the grosser perception of the alternation of inhaling and exhaling, you can guide your clients to notice a host of subtler details in the breath:

• The coolness at the back of the throat as air moves into the lungs

• The peculiar sensation of air coursing in through the nostrils • The rise and fall of the belly • The tightness in the chest as the lungs reach their full capacity

• The

warmth that rises in the back of the throat on exhalation

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The list goes on. Deep and profound formal mindfulness practice can center on awareness of the breath. The same sort of winnowing of more prominent aspects of experience to more subtle ones can be done with tactile sensations. To guide clients through this awareness exercise, begin by having them notice the feel of their whole body as they sit in the chair. Then have them notice the sensations of their feet touching the floor, the places where their body touches the chair, and the places where their clothing touches their skin. Have them further concentrate their attention by especially noticing the margins—the areas right at the very edge of where clothing touches and does not touch. Guide them to notice the tiniest details of sensation that tell them where their clothing touches and where it does not. Have them trace the edge of these margins in their imagination as they notice the sensory details along that transition between touching and not touching. These small details, which require a great deal of attention, assist in bringing intentional, focused awareness to the present moment.

From Then to Now Another method of focusing attention is to start with the stream of activity that brought clients to session. Walk the clients through the time prior to coming to session—noticing the activities of the day, going to work, driving to the appointment. Ask them to let their attention touch lightly on the things they were thinking and doing as they came to the office, what they were thinking and doing as they sat in the waiting room. Direct them to see themselves as they walked into the room and came to rest in the chair, as they closed their eyes and finally found themselves sitting right here, right now, in this very moment. Here is a short script of what this might sound like. Remember that this is just a guide. Your own experience will inform how this exercise might sound in your own therapy room.

Stream of Activity Mindfulness Exercise Script I would like for us to start with a mindfulness exercise to see what it is like to stop and pay attention to the details of everyday life. These types of exercises may help you get into the room, into the here and now, and to notice how quickly thoughts take us away from experience. You can’t learn unless you are here inside the room. 89

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[Try to incorporate details of your client’s activities, if you know them, to make the experience more personal and relevant—names and familiar places and situations would be helpful. Present this in a slow, deliberate fashion with pauses—good long pauses. Use your volume, tone, and prosody of speech to capture your client’s attention.] Just take a second to settle in. Just let yourself settle into your chair. Let your eyes shut gently. If you would, follow the sound of my voice, and if you find your mind drifting, notice it and come back to the sound of my voice. I want you to let your mind trace the steps you took to get here today. [Pause.] Picture that process—getting up—the routine of getting ready. Notice it like you’re watching a movie of yourself. Maybe you had plenty of time or maybe you were in a hurry. See if you can remember your concerns and thoughts as you were preparing to get here—things during the day you need to do. Let yourself notice the busyness of that moment. [Pause.] Notice getting into the car—making it here—just notice that. Now, sort of push forward as you move toward getting here. See if you can recall what your body felt like when getting here—the places you passed by—just let it tick through your mind. Picture yourself arriving here—at this building. [Pause.] Gently watch those interactions with others as you arrived—just notice each one. And finally notice settling into your chair—where you find yourself—right now. See if you can just imagine that the strands of activity that brought you here today are some kind of fibers connected to you. Just imagine that the strands that brought you here gently begin to drop away with the inflow and outflow of your breath. Just breathe—let yourself continue to notice those strands dropping off slowly until you’re just sitting in your chair right now. [Pause.] Let yourself become aware of your body and your breath. [Pause.] Let yourself become aware of your hands and the place where they rest. 90

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eye.

Notice the place where they touch and the edges of those places. See if you can trace the outline of that slight pressure with your mind’s

See that shape of each place where your hand touches—just breathe. See if you can begin to notice the tiniest sensations in your hands—the smallest tingles—feel the blood moving. Draw your attention now to your breath. Take three very gentle, full, mindful breaths. Notice each small detail, where you notice the inflow and outflow of each breath. Now gently, gently let yourself come back into the room. When you are ready, open your eyes. Depending on how seriously you take the injunction to make your pauses good and long, this exercise might take you anywhere between five and ten minutes. Done with care and intention, it can really transform the feeling of the room and make space where good work can be accomplished.

INTRODUCING MORE CHALLENGING MATERIAL Thoughts, memories, and emotional reactions can be good material for mindfulness exercises, but beginning with sensory details and then moving to these more challenging domains is often a good strategy. To put it in technical terms, with some exceptions, sensations, sounds, and so forth are likely to carry fewer verbal-evaluative functions and therefore are less likely to generate fusion and avoidance. In other words, the awareness of the sensation of a chair on the back of the legs or the coolness of the breath on the upper lip are far less likely to be distressing to a client than, say, evoking the thought of a hectoring boss, a moment of trauma, or another lonely night spent despondent on the couch. There are exceptions, of course. Noticing heart rate might be very loaded for a person with a history of panic, yet for someone with no panic history, focusing on the heartbeat can be a nice, quiet meditation. Likewise, a person with a severe sexual abuse history might struggle with body awareness, but perhaps less so with becoming aware of the variations in temperature of the hands. 91

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As a general guide, begin with a focus on events with a reasonably low verbal-evaluative load. After establishing a mindful, focused state, move on to more challenging material. Informed consent is a necessary part of this work (and a subject covered thoroughly in other ACT books). When materials are likely to be challenging for general reasons, like thoughts, or specific reasons, like heart rate for someone with a panic disorder, spend a bit of time making sure that the work you’ll do will be done with permission. Also, in order to take advantage of the flexibility in responding produced by mindfulness, you should make a point of moving gently and flexibly between difficult content and the breath or some other more neutral focus. Don’t mistake this shifting of focus for avoidance of painful experience, though. The purpose of the return to breath isn’t to attenuate the intensity of the difficult content; rather, it’s to remind us that there’s more to the world than the hard things we sometimes find in it.

VIOLATING CATEGORIES AS A WAY INTO THE PRESENT MOMENT The uncategorized world is a scary place. Humans love to make categories and to fit everything into them. If something doesn’t fit in a category, it goes into a category of things that don’t fit (and we need to get those things figured out right away). Categories are great. If you have insurance policies categorized as good ones and bad ones, you can pick a good policy. If we have categories of routes home that are good and bad, we can pick the best route. Categories also have a downside. They rob us of the intimacy of immediate contact with our world. Our categories often pull us out of the here and now of experience. We chunk the world into categories, yet, like all representations, the categories should not be conflated with that which they represent. René Magritte illustrates this elegantly in La Trahison des Images (The Treachery of Images), his painting of a smoking pipe floating above the legend Ceçi n’est pas une pipe— “This is not a pipe.” This seems cheeky at first, but if we think about it, Magritte is clearly correct. The painting is ground pigment and oil dried on a canvas in a convenient arrangement that evokes in many of our minds the notion of the smoking article. It’s most emphatically not a pipe. In an important sense, all categories are lies. Sometimes they’re useful lies, but it’s important to remember that the categories don’t exhaust the phenomena categorized. 92

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USING THE EDGES, MARGINS, AND SPACES IN BETWEEN IN MINDFULNESS One way to temporarily circumvent the mind’s insistent and persistent categorization is to violate the rules of categorization. These violations can pull us into the present moment. I’ve had a very long love affair with margins, with hesitations, with interstices, with the spaces in between. When I’m guiding someone to notice temperature variations in her hands, I might ask her to notice the very edge of the sensation. I might ask her to imagine that she can feel each individual cell and to allow her attention to move from an area that’s clearly warmer outward, cell by cell, feeling her way to the edge of that variation, to that tiny margin that’s right in between warmer and cooler. In another variation, I might tell a person that I’m about to say some words, and that I’d like him to notice the space between the words. Then I might roll back and forth over the words, allowing good long pauses between them. I might ask the client to attend carefully to the fullness and texture of that space between the words. You might try this with a colleague or client, or try it on your own. Do this with significant words: “I’m a father.” “I care about my body.” Go very slowly, and do this repeatedly. The first few passes will be very noisy; your mind will complain. First it will complain that there’s no point. Then it will complain that it gets the point, so there’s no need to go on. Give your mind a kindly pat on the head and stay with it. Listen for those spaces between words. Persist and those spaces in between will fatten up psychologically. Really! They will. Just persist.

MIXING CATEGORIES TO DISRUPT CATEGORIES Another way to disrupt the categorized world is to mix categories in ways that violate the commonsense properties of the categories—for example, give visual qualities to tactile events. Have your client close his eyes and direct him to attend to his breath. After he settles a bit, ask him to imagine that he can see his breath as you might on a very cold day. Ask him to picture his swirling breath as it enters and leaves his body. Ask him to let his breath take on colors, perhaps blues and greens on the cool in-breath and oranges and reds on the warm out-breath. 93

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Many Gestalt-type imaginal exercises have this quality. These exercises often involve having a client visualize a difficult emotion, then give color, shape, texture, temperature, and size to the emotion. In the next chapter, where we’ll discuss ways clients break contact with the present moment and how to help them come back, we’ll describe the ACT processes through which these sorts of exercises are thought to work and offer detailed instructions on how to carry them out in the therapy room. For the purposes of this chapter though, it will suffice to say that these interventions disrupt the categorized world a bit and make contact with the present moment more likely.

ASKING QUESTIONS DURING MINDFULNESS EXERCISES Although traditional mindfulness practice does not involve questions and answers, the sort of exercises described here can often involve some questions. When you need to ask questions, tell the client before the exercise that you want very brief and minimal answers. Tell her that, if you need more information, you’ll ask for it. Also tell her that she shouldn’t stop the exercise to answer. She shouldn’t, for example, open her eyes and talk with you as she might in a conversation. If the client does stop the exercise to talk, gently coach her to close her eyes again, use a few words to refocus her, and ask the question again. Again, we’ll talk more about this in chapter 5. For now, just note that mindfulness work can contain questions, although they need to be handled delicately and with some care.

INITIAL VS. LATER MINDFULNESS EXERCISES As is true generally with experiential exercises, there are individual differences and, within these, differences in individual learning curves. Some clients will be able to participate in the exercises right away. For others, it will be a struggle. They’ll find themselves moving in and out of the exercise. As a rule, your clients will improve over time as a function of repetition—and so will you. The more consistently you do these exercises, the better your clients will get at them. Early on the exercises 94

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will likely need to be longer, which might seem counterintuitive if you have a formal meditation practice of your own in which sittings tend to get longer and longer with greater skill. The exercises you do with your clients early on will require more meticulous attention to detail as you direct their attention to various sensory experiences. After they become more adept, they’ll be capable of moving with relative ease from ordinary conversational modes into a relaxed, mindful, present-moment-focused state—and so will you.

EYES CLOSED VS. EYES OPEN Some clients have a difficult time closing their eyes. I’ve seen this numerous times, for example, with individuals who have been victims of physical or sexual assault. If they do, ask them to cast their view down and to allow their eyes to focus on a spot on the carpet. In doing so, we disrupt the social and conversational aspects of the interaction by keeping the visual focus on something other than the therapist’s face and posture (as would be usual in most social interactions). Ask them to let their eyes fall partway closed if they’re comfortable with that. You can often gently coach such clients to close their eyes more and more over time. Bear in mind that there’s nothing magical about keeping your eyes closed. Closed eyes simply reduce visual input and, importantly, significant nonverbal social input from the therapist. These minor variations on eyes closed can accomplish the same thing.

TIME TO PUT DOWN THE BOOK AND GO FOR A WALK OUTSIDE You were so riveted that you plowed right from the introduction to this point, right? Who could blame you? Technical behavior analysis and a discussion of mindfulness processes is griping stuff. In truth, I’m a little shocked that no one has optioned the movie rights to this thing—at least they haven’t yet. But seriously, this is more or less the halfway point of the book, even if I haven’t filled up more than half of the pages. So far I’ve described a personal psychology that’s grounded in the commonality and ubiquity of human suffering, in the urge to problem solve, and in our dis-ease in the face of ambiguity—a psychology that is likewise grounded in a drive to 95

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seek liberation from these constricting forces for the purpose of allowing us and our clients to live richly vivid and purposeful lives. I’ve situated this personal psychology within a theoretical framework, and I’ve either introduced you to or reacquainted you with some of the basic behavior principles that can animate and enliven your work with clients. I’ve connected ACT to the tradition of behaviorism, and situated the practice of mindfulness centrally within the ACT process model. And finally, I’ve explored the mindfulness practices and shorter mindful moments, proposing a technology of mindfulness that can be useful to you in your clinical work. So what’s next? In the chapters that follow, we’ll take a look at the specific kinds of opportunities you’ll encounter in the therapy room for fostering greater contact with the present moment through mindfulness. We’ll also take a look at a “field guide” that will help you recognize the telltale signs of mindlessness or a lack of contact with the present moment in both your clients and you. We’ll dive into the wild world of transdiagnostic, hexaflex-oriented case conceptualization. And finally, I’ll share some annotated scripts of several exercises for fostering greater presence. In the meantime, though, put the book down (even if you didn’t read straight to here, no one’s watching.) Stretch your legs. Take a few deep breaths. Get some coffee or go for a walk outside. What’s going on in the world? Maybe the sun is setting or rising. Maybe your kids are outside playing. Maybe someone you love is watching TV in the next room. Maybe, even now, your clients are out there somewhere, doing the best they can to live their lives in a way that matters. Before you go on to the rest of the book, take a moment to sit inside this question: what is the reading I’m doing here in the service of? Don’t struggle for an answer. Just linger in the question. When you’re ready, please join me in chapter 5.2

2 Look at what you wrote. Did you write, “Paris in the spring?” Now go back to the text and notice that the word “the” is repeated in the sentence. This is an example of the part-attention we often pay to the stream of words that pass by us every day. 96

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Clients and the Present Moment

Chapters 5 and 6 work together to fulfill the ambition of this book’s title; they develop a stepwise approach you can use to foster mindfulness for two. In this chapter, we’re going to look at client presentations and opportunities for growth. In chapter 6, it will be your turn as we shift our focus to the therapist side of things. These chapters answer the questions “What does this stuff look like?” and “How do I do it?” Built on the foundation laid in the first half of the book, what follows will give you a significant set of practical skills and approaches for integrating Â�mindfulness into your therapy sessions.

COMING TO THERAPY From an ACT perspective, fusion and avoidance drive a tremendous array of psychological difficulties. We began this book by taking a hard look at the ubiquity of human suffering and at the flip side of that suffering— the ubiquity of human problem solving. Our clients come to us because they’re suffering. They’re suffering, and they’re also doing something else, something very sensible. They’re doing everything in their power to end that suffering. From an ACT perspective, it’s not the suffering per se that takes away from life as much as it is our propensity to resist suffering. What we ask clients to do in ACT is to let go of wholly sensible attempts to solve the fundamental problem of human suffering.

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Why? Why should they let go of such an entirely sensible enterprise? We ask them to do this because we believe that, if they stop struggling for just a moment, they’ll see the cost of the struggle stretched out across their lives and the lives of those they love. And if they can bear that, for just a moment they’ll see precious things, rich and beautiful things, that could fill their days. How do we slow them down enough so that they and we can see this? We must meet them.

MEET YOUR CLIENT If we’re to meet our clients, we must meet them where they are. Our clients live inside stories about the world. I don’t mean that the stories aren’t true. Often they are. But the world is much richer than any story about the world. In ACT, there’s an assumption that clients can navigate more effectively if they’re in better contact with the richness of the world around them as opposed to the story about the world that their minds deliver to them (and to us all). What’s the role of mindfulness in this contact? To put a fine point on it, from an ACT perspective mindfulness is viewed as the bringing of flexible yet focused attention to bear in the present moment, and in a certain way:

• With equanimity for that which is encountered • Noticing verbal presentation of the world in thoughts as thoughts

• And with all this done by a “you” that transcends the contents of consciousness

You might better recognize these three points by the handles we commonly affix to them in ACT: acceptance, defusion, and self-Â�asÂ�context. From an ACT perspective, with the exception of some situations involving relatively immediate harm, it is in mindfulness that we are best prepared to meet the world, to notice what we value in it, and to gently turn toward that which we value. What keeps clients out of the present moment? From an ACT perspective, great suffering emerges from two major sources: fusion and avoidance. Fusion with a story about the world tells us the limitations inside which we must live. It tells us what’s possible and what’s not Â�possible. It tells us where pain was, where it is now, and where it’s likely to be in the future. It tells us what we could do to prevent or attenuate 98

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pain and suffering. Experiential avoidance is a wholly sensible response to a world construed in this way. What happens? We shrink from the dangers of the world. We shrink from the unknown where danger might be—the bear that might be crouching behind the blueberry bush. We shrink our lives into something small and knowable. We shrink into what Thoreau called lives of quiet desperation, what Eliot called lives measured in coffee spoons. We shrink. We shrink, but there’s really no place to hide. Like cringing in the rain, we still get wet.

RECOGNIZE THE SMALL SPACES CLIENTS INHABIT If I could only offer one principle to organize your behavior, it would be this: watch for narrowness and inflexibility in your clients’ behavior. Narrowness and inflexibility are important, if you recall from chapter 2, because they’re hallmarks of behavior under aversive control—another way of describing avoidance—and also hallmarks of behavior under verbal control, which is to say, fusion. In what follows, we’ll examine the various forms this narrowness might take and ways you can help expand the behavioral possibilities for your clients (and yourself) by contacting the present moment more fully.

COMMON PATTERNS OF FUSION AND AVOIDANCE AND FAILURES OF PRESENT-MOMENT PROCESSES In a certain sense, we can think of almost all forms of fusion and avoidance as failures of present-moment processes. Some of these patterns are likely to emerge quite directly in your sessions. Chief among them are worry and rumination, although there are others we’ll examine, including storytelling, keeping conversations trivial, and others. These don’t exhaust failures of present-moment processes. For example, in chapter 7, which explores experiential case conceptualization, we’ll discuss inflexible planning and preparation as some other instances of the failure of present-moment processes. We’ll wait to discuss these until later, though, because they’re less likely to appear directly in session or to interfere with present-moment processes in our sessions. 99

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Worry and Rumination Rumination and worry have been connected to negative outcomes in a large number of studies (e.g., Miranda & Nolen-Hoeksema, 2007; Hughes, Alloy, & Cogswell, 2008). In many respects, rumination and worry are two sides of the same coin, with rumination gazing back over the past and worry looking out toward the future. They’re alike in that they both involve verbally grinding over a time that’s not now. Worry and rumination are examples of fusion because the storied version of events dominates over the potential richness of experience. The dominance of the storied version not only applies to the details of the events described in the stories themselves, but also to the qualities of experience that are present in the moments spent grinding over the story. Please be clear, when I say “story,” I don’t mean that the events described in the story never happened. Consider, for example, an individual who ruminates over a childhood in which she was always the last person chosen to play on school-yard sports teams. This person may go over and over the story: I was too awkward. I was too shy. The other kids were unkind. She may well have been shy and awkward, yet she was also a child, a vulnerable human being, and lovely in her own right. But the latter is likely lost in the midst of the former. Sometimes when stories are true, they are even more troublesome. We put a lot of stock in truth, even when engagement in ostensibly true stories takes us nowhere. Worry, rumination’s futurized twin, often shows the same unworkability. A socially anxious person may worry about how he’ll do in a social situation. “What if I’m awkward or nervous or say the wrong thing? They won’t like me.” Of course, a person with a long history of social anxiety who has carefully avoided many, many social interactions is more likely to be awkward and nervous and to say the wrong thing. The chances are high that other, more socially skillful individuals will notice his social deficiencies and respond accordingly. However, sitting at home worrying about how social situations will go won’t improve his social skills one iota. The only way into the social game is to step into gatherings, exchanges, and conversations—to guarantee exactly the poor performances that he’s engaged in fearing. The stories that are keeping him out of social interactions—whether they’re far-fetched or as sure as Sunday—will all have exactly the same impact on his social life, which is to cause it to wither away and die. In rumination, we grind over the past. We relive our history in imagination. With worry, we relive feared futures over and over. As Â�behaviorists, we assume that this pattern of activity is functional. So our 100

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next question is how does it function? If we assume that rumination and worry either produce something or promise to produce something positive, or reduce or promise to reduce something negative, what might that be? First, let’s look at what they promise to produce.

THE PROMISE OF RUMINATION AND WORRY Let’s look at some examples of worry and rumination and try to tease out what their behavior function (or “promise”) might be.

Ruminating about what we (or others) said or did, or didn’t say or do. If you ordered the daily special at a local restaurant several times and each time the meal was bad, you might come to the conclusion that the special was something to be avoided. If you ended up on a dead-end street while attempting to find a friend’s house, reviewing the route might help you find out where you made the wrong turn, which could help you avoid making the same mistake again. You might not spend much time reviewing a missed turn or a bad meal, but what if the cost of the past event were greater than having to choke down some leathery chicken or arriving at a party ten minutes late? Perhaps you were betrayed by a lover, you lost something precious to you, or you failed at a work endeavor. What if the costs of these events were the loss of your marriage, the custody of your child, or a job that you really enjoyed? It would make perfect sense for you to want to be absolutely certain you fully understood the errors that caused you to pay these high costs in your life. You might mull over the daily special or the directions to the party for a few minutes; for more consequential events, however, you might devote a significant portion of your thoughts for the rest of your life. The promise of this sort of rumination is that it will prevent recurrence of significant negative events. Self-recrimination about the past. We all have rich histories of punishment for misdeeds or even for poor performance. Delivering punishment somehow sets the world right. In addition, we imagine that the punished person is less likely to commit the bad act again. It’s worth noting that the supposed bad act need not be bad from the perspective of others. When Cathy Freeman, the Olympic gold medal runner, retired from competitive sports in 2006, she remarked, “I have struggled with my motivation for so long. I could no longer disguise from myself that I had simply had enough… My depression stemmed from the fact that I had come [in] a poor fifth, way behind the world leader in my event, Ana Guevara, of Mexico, and—you know what?—I didn’t feel distraught.” However, from the interview it was clear that she was quite distraught about not being distraught. 101

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Her comments are telling of the human condition. This remarkable woman placed fifth among the fastest women in the world, and that was a sign of poor motivation. Further, not remonstrating herself was itself an additional flaw. I was visiting Australia at the time, doing some workshops, when I saw the coverage of this event. As a father of daughters, I wept. When you ask people what it would mean to let go of punishing themselves for past misdeeds, it’s altogether common for them to reply that the punishment somehow keeps them in line. If they were to stop, nothing could prevent them from being lazy, bad, unkind, foolish, and so forth. Going over past misdeeds promises to keep unruly behaviors in line.

Worrying about the future. Worrying about the future is simply the mirror image of rumination about the past. The worrier imagines scenes and scenarios and all of the things that might go wrong. The promise inherent in worry is that if we worry long enough and hard enough and carefully enough, we’ll be saved from these feared futures. Worry and rumination to find reasons. Whenever something bad has happened, there’s a strong tendency to find fault or cause—a reason why. The guilty must be exposed. Watch a movie, read a book, listen to a story. Notice how unsatisfying it is when the story or book or movie ends, and we have no idea who is at fault for the mishap around which the story swirls. Another reason we strive so hard to find fault is that we live in a culture that tells us that negative outcomes are often deserved. This sensibility is so pervasive, there is even a generic name for it in social psychology: the just world theory (Lerner, 1980). The just world theory is derived from experimental findings in which people show a remarkable tendency to believe that, when individuals experience bad outcomes, they probably, somehow, had it coming to them. When we suffer some negative outcome, we feel a strong urge to wonder what it is about us that brought it on. We like a coherent world, a world that makes sense. If we find ourselves in a bad way, there’s a tremendous pull to come up with a reason. Attributing the bad outcome to some personal flaw (specifically identified or not) at least gives some sense of resolution about why. We like to know why. Think about how many times you or someone else has done things after which you were left wondering why. Why did my relationship go bad? Why am I so stingy? Why don’t I ever get a break? Grinding over such questions again and again can become a life’s work. If we look at workaday events in the world, we’ll find that searching for reasons why is often quite useful. If your airline ticket is extremely expensive and you do some investigation, you might find that traveling 102

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on a Wednesday is far less expensive than traveling on a Monday. The next time, you might plan your trip accordingly. If the police examine a crime scene, they might find a perpetrator, who might then be apprehended and incarcerated, and we might all be a little safer. If your checkbook doesn’t balance, you might go carefully over each entry until you find the error. In the end, you might discover why the checkbook hasn’t balanced and more importantly, what your available balance actually is. When applied to transactional events in the world, an understanding of causes and effects gives us great power to steer our lives in the directions we would prefer. But let’s look at some questions that are a little more meaningful and perhaps a little more personal—and certainly a lot more complex. Why do relationships never work out for me? How did I end up in this dead-end job? Or, better still, why am I so depressed? Or anxious? Why didn’t I say yes when I really didn’t want to do it? Why do I keep drinking? It doesn’t take many hours in the therapy room to see that people can spend their whole lives asking questions like these over and over again. And often, having failed to come to any resolution, they attempt to co-opt the therapist into the task. But try to intervene in the story. See if you can move it around. Reinterpret it. See if you can come up with a piece of contrary evidence that cannot be offset. If it’s not impossible, it’s likely to be very, very hard. If a person is easily moved from such a conversation, we wouldn’t be hearing about it in therapy. In situation like this, where refutation and counterargument just lead to more wheel spinning—more worry and rumination—a moment of mindfulness just might allow the client to find a spot, just one lingering moment, where she can rest.

THE IMMEDIATE BENEFITS OF RUMINATION AND WORRY Rumination and worry both promise to deliver a better future, but they also deliver something in the here and now. There’s a reinforcer intrinsic to engagement in the pattern of activity itself. What does it keep at bay? In the face of uncertainty and risk, vigilance is its own reward. Worry and rumination, thus conceived, are a form of problem solving. In problem-solving mode, we can at least maintain the illusion that we’re doing something productive. There’s comfort in that. What worry and rumination also do is take us out of the moment we’re in. If being in our own skin is a very hard place to be, anywhere else could potentially be more comfortable. We’re used to thinking of methods of 103

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escape from pain as being pleasant—drugs and alcohol, for example. Why would anyone escape to a difficult place? Self-harming clients are a grim reminder that escape need only to be relatively more pleasant. If the pain of being present is great enough, worry and rumination, though terrifically painful themselves, can be good places to hide.

Storytelling Our clients don’t live in the world directly. None of us really do. We live in a storied version of the world—a world modeled by the savanna minds of our distant ancestors, shaped by countless generations of constant fear that we might either starve to death or be devoured by something with sharper claws and stronger jaws than we might ever hope to possess. It’s just a story. Of course, storytelling isn’t a bad thing in and of itself. You’ve probably guessed by now that I love a good story. But there’s a version of storytelling that’s indicative of a failure of present-moment processes. I raise this here because it will appear in session and directly interfere with just about any intervention you might hope to provide. Storytelling can take a lot of different forms. The invariant and inflexible quality of this sort of storytelling is the feature that you’ll want to learn to recognize and work with. There are several versions of storytelling. Sometimes the stories will be about negative instances in a client’s history that are raised again and again. These are in-session instances of rumination. Sometimes the stories will be very proximal and won’t involve repetition of longpast personal history. Instead the client may insist on a mind-numbing, moment-by-moment recounting of every difficulty that occurred in the past week. In this recounting, the client lists the problems in hope that if the problems are delivered comprehensively and in enough detail, you’ll be co-opted into joining him in the problem-solving task. Unfortunately, this latter kind of storytelling can, at least initially, be compelling to us as therapists. In the rehashing of this list of events, we may be able to find something we can work on. But over time, this pattern is wearying. There seems to be a never-ending supply of problems. Probably the best indicator of this kind of storytelling pattern is when we, as therapists, find ourselves wrestling with incredible feelings of boredom and frustration. (In chapter 6, I’ll discuss some ways of dealing with these, our own failures of present-moment processes.) As with rumination and worry, this pattern brings some relief to the client because he at least feels as if he’s working hard. 104

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Another variation of storytelling involves the repetitive description of a better time. This sort of reliving in story has several appetitive functions for the client. It may provide her with a sort of euphoric recall. It may also reassure her that something positive is possible, or at least has been possible before. She may find some relief in the hope that she will eventually find her way back to that better somewhen else. Such stories may also serve a social function for the client with respect to the therapist—a way of saying, “See, I haven’t always been such a mess. There’s more to me than these problems.” A final storytelling form worthy of mention is keeping the conversation trivial. A conversation filled to the brim with trivialities has no room for more profound (and more frightening) conversations. Variations on this might include talking about the news, sporting events, or the weather. This is the sort of conversation likely to leave you wondering, “Why is this person here?” The casual quality of the conversation is belied, though, by the ways in which your client systematically obstructs all of your attempts to switch to a more significant conversation. In this and all of the cases of avoidant storytelling, that is present-moment process defeating, keep an eye out for any sort of conversation that has narrow and inflexible qualities.

Apologizing A last indicator of the failure of present-moment processes commonly seen in session is persistent apologizing. It’s ironic that clients come to therapy and apologize for having difficulties, yet we observe it all the time. When clients persistently feel the need to apologize—for interrupting you, for being upset, for forgetting to do homework—it’s likely that they’re monitoring their relationship with you very carefully. Persistent apologies may function to ward off anticipated rejection. To get a sense of the narrowness of this pattern, try pointing it out. The most common response will be to apologize for the apologies.

MINDFULNESS, MINDINESS, AND PRESENT MOMENT In chapter 3, I suggested that there’s an inverse relationship between being in the present moment on the one hand and fusion and Â�avoidance on 105

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the other. One sure sign than clients are slipping away from the present moment is the emergence of what I playfully call “mind-y” conversations. Mind-y conversations are those conversations our clients have with others (including us) and with themselves that contain a lot of fusion and avoidance. You can become skilled at recognizing mind-y conversations and how to intervene in them. In the next chapter, we’ll look at the ways these mind-y conversations can hook you and the work you can do to open up this bit of inflexibility. For now, let’s examine the kinds of things you can watch for in your conversations with clients that can indicate mindiness.

How to Detect a Mind-y Conversation We have mind-y conversations with our clients, and they’re constantly having mind-y conversations with themselves. Mind-y Â�conversations have very particular qualities: comparison and evaluation; complexity, busyness, and confusion; statements conjoined with “but”; adversarial posturing and side taking; strong future or past orientation; strong problem-solving orientation; strong focus on what something means about the client with respect to others; explanation vs. description; categories vs. specifics; and the familiar. Let’s take a look at each of these qualities now.

COMPARISON AND EVALUATION Mind-y conversations invariably compare (often dissimilar) things, make evaluations, and level judgments: this thing, person, situation, time, or place is better or worse than that other thing, person, situation, time, or place.

COMPLEXITY, BUSYNESS, AND CONFUSION Even direct, present conversations can be complicated, but mind-y conversations can be positively labyrinthine, going every which way and doubling back over ground already covered. In addition, mind-y �conversations often contain a demand that the complexity be solved before life can improve. Why did this relationship not work out? Maybe I should have been more attentive. But then, it seemed like I was being attentive. And when I was particularly attentive, she seemed to get mad. But maybe it was the wrong kind of attentive. Maybe I was smothering her. I just never 106

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learned how to be with anyone. But how can I learn that if I can’t keep a partner? Maybe she’ll take me back—give me another chance. But even if she does, I don’t know what to do different. But if I don’t try, it will never work. But I don’t know what to do. So the conversation goes, ad infinitum. Sound familiar?

STATEMENTS CONJOINED WITH “BUT” When looking for this and other aspects of mind-y conversations, it’s worth listening for the word “but.” Etymologically, “but” comes from a contraction of the verb “be” and the word “out.” Statements that are introduced with “but” may quite literally be thought of as asserting “be out that,” where “that” is the material that follows. There is a demand for resolution inherent in the verbal formulation “If I don’t try, it will never work, [be-out] I don’t know what to do.” “I don’t know what to do” has to go away before I can try. Our minds give us this formulation as surely as an apple falls to the ground when dropped. Sometimes we’ve talked about ACT as a treatment that gets people off their “buts.” You might be tempted to refute the immutability of the conclusion arrived at by a “but” formulation. There are a lot of treatments that have worked on that basis. You’re welcome to try it. But if the conversation is grounded fusion and avoidance, I predict that any refutation you come up with will produce either mere compliance on the part of your client or more of the same mind-y conversation. Either way, you’ll still be disconnected from the present moment, and your progress with be impeded.

ADVERSARIAL POSTURING AND SIDE TAKING Mind-y conversations will often have an adversarial quality. You can hear some the adversarial quality in the conversation above, about whether or not the client could sustain a relationship. The argument that hypothetical client was having with himself could easily have been between him and his partner, and the dialogue might not have been much different.

Joe:

Why didn’t this relationship work out?

Judy: Maybe you should have been more attentive. Joe: It seemed like I was being attentive. And when I was particularly attentive, you got mad at me.

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Judy: Maybe it was the wrong kind of attentive. You were smothering me.

Joe:

I just never learned how to be with anyone.

Judy: You never will learn if you can’t keep a partner. Joe:

Won’t you take me back—give me another chance?

Judy: Even if I did, what would you do differently? Joe:

If we don’t try, it will never work.

Judy: But what would be different? Joe:

I don’t know.

If a client is locked in an adversarial conversation, avoid being drawn into it. Whatever position you take, you’re likely to fail. After all, your client has mostly been having this conversation inside his head and has far more practice at both sides of the conversation than you!

STRONG FUTURE OR PAST ORIENTATION Mind-y conversations are usually littered with either warnings about the future or reprimands about the past. Sometimes the warnings are only implicit. If you listen hard and ask the right sort of questions, you can hear the warning lurking behind what is said.

Client: I thought I was going to start crying right there in the staff meeting. I can’t look weak at work.

Therapist: Help me to understand what’s at stake. Imagine for

just a moment that you broke down crying. Then what would happen?

Client: Well, they would see how weak I am. Therapist: And then what would happen? Client:

I just couldn’t do that! It can’t happen!

Therapist: Sure, I understand. I’m not asking you to have that

happen. And I’m not saying it’s a good idea to let it happen. I’m just trying to see clearly what’s at stake for you here. You don’t have to actually cry in a staff meeting. Just imagine what it would be like.

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Client: It’s crazy. I don’t even know why I was so upset. It doesn’t make sense.

Therapist: Sure. Okay. Just close your eyes for a moment and let

yourself see that room. Hear those voices. And imagine that the tears just start streaming down your face. What happens next?

Client: Well, everyone is looking at me. God, this is awful. I

can’t believe I’m doing this again! Why does this bother me so much?

Therapist: Okay, now. Slow down. And breathe. And let’s just

stop there a moment—as if you could stop time. And just breathe—gently, gently. And as you breathe, let your eyes travel across those faces. Let it be as if, in this moment outside of time, you can look at them without them seeing that you’re doing that. Imagine letting your eyes rest gently on each face…lingering…then moving to the next. What do you see?

Client: I see pity in their eyes. They think I’m weak. I feel so ashamed.

Therapist: Okay. And breathe. Can I ask you to just stay with this

another minute? And breathe—breathe—gently, gently. So they think you’re weak. And what do they want to do with you?

Client: They want me to leave. I’m too much. Just on the other side of “I can’t look weak” is a warning about the future. Listen for words like “must,” “should,” “can’t,” and “have to,” all of which point to the future. Listen and inquire for “have tos” and consequences. I have always thought that some of the genius of Albert Ellis was his interest in “shoulds” and “musts” (and their cousins, “shouldn’ts” and “can’ts”). Conversations like this are often also filled with reprimands both explicit and implicit. You can hear in the dialogue above the selfÂ�contempt for weakness. These conversations provide the illusion of doing something about “the problem”—warnings to forestall future failures, reprimands over past failures to make those failures less likely to happen again. But where do these conversations go? Do they actually take the client anywhere at all? 109

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STRONG PROBLEM-SOLVING ORIENTATION These conversations will often have the strong flavor of problem solving. The content will present itself as a problem requiring resolution right now, before anything significant can move forward. This is particularly suspicious since the so-called problem being solved has often been hanging around unsolved for a very, very long time.

STRONG FOCUS ON WHAT SOMETHING MEANS ABOUT THE CLIENT WITH RESPECT TO OTHERS Not all values are connected to our relationships, but many, many are. And since values and vulnerabilities are poured from the same vessel, issues that touch on our relationships with others are fertile ground for fusion and avoidance. Mind-y conversations often focus on what something means about a client in relationship to others or what others will think about the client as a result of whatever the client perceives as the problem. Listen for content that has to do not only with the nominal problem but also with the implications that problem might have for relationships. If you want to see how this works, check it out using your most precious story about what’s wrong with you.

EXERCISE: What’s Wrong with Me? Take a moment and think about the thing you least like about yourself. Read the following statements—slowly, carefully, lingering over each. Read them aloud. See if you can notice some small (or maybe not small) seeds of each in you. As you speak each one, allow yourself to own it for a moment. Notice what shows up when you say it. What thoughts, memories, and bodily sensations come up? Notice how much you’re ready to move on to the next item on the list or to skip this exercise altogether. Before you even begin, see if you don’t have a bit of “Not right now,” or “Sure, I get the point,” or “I don’t get the point.” Notice if your mind is trying hard to get you to run the other way. Note that getting the point is not the point, though. Making contact, getting present, having the capacity to sit in hard places when sitting in hard places could make a difference—that’s the point. So I invite you to do just that.

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• I’m selfish. I act like I care about a lot of things, but really I don’t.

• I’m needy. A lot of people don’t really see it, but I live and

die on their criticism and praise. I’ll do just about anything to get people to like me. I can’t believe some of the things I’ve done.

• I’m not really very smart. People think I’m pretty smart, but really, I work very, very hard and just barely keep up with everyone else.

• I’m secretly jealous of others. I get mad when good things happen for other people. I never say anything to them, but sometimes I say things behind their backs.

• I just have to have the last word. It has cost me a lot over the years, but I just can’t seem to keep my mouth shut.

• I’m lazy. Mostly people don’t notice, but when they aren’t looking, I get almost nothing done. I’m a lump.

• I’m a coward, a doormat. I let people walk all over me. I get mad, but I never say a word.

• I’m unlovable. I’ve had relationships, but eventually people get to see the real me and they leave. Sometimes I’m hopeful, but really I know that it’s just a matter of time.

• Deep down, there’s something missing from me. I’ve never been sure what. I look around and other people seem fine. But me? It’s like there’s a hole.

• I’m fragile. • I’m bossy. • I’m ugly. • I’m boring. • I’m mean. • I’m impatient. 111

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What is it that’s wrong with you? Pause and just spend a moment inside that question. What’s wrong with you? Being weak means being shunned. Being stupid means being shunned. Being inadequate, boring, ugly, lazy, jealous, and so forth means…what? In the end, these all have implications for our relationships, for the possibility of relationships, for the future of our relationships. And all we need to do is look at our past for that evidence.

What does it mean to our clients—to all of us—to live our lives under this kind of burden?

EXPLANATION VS. DESCRIPTION A common variation of the mind-y conversation is the explanation. It’s worth distinguishing two very different functions of explanation. One variant of explanation is really just description. The other involves description but contains a subtext of social evaluation. To give an example, I might explain the life cycle of the frog— from egg to pollywog, the metamorphosis into a frog, and so on. There’s nothing particularly socially meaningful about this explanation. Some explanations, though, include an important social exchange. If I treated my spouse with jealousy and distrust and caused problems in my marriage, you might think I was a bad husband. If I went on to describe a horrific history of abuse in my own formative relationships and also to explain all of the very good things I do in my marriage, it might mitigate how you perceive me. You might take a more forgiving view of my behavior. My explanation might describe to you the details of my formative years and my married life, but functionally it would also seek to alter the relationship I have with you and likely the one I have with myself as well. When you’re talking with a client, listen for subtexts that seem to request a social get-out-of-jail card, your implicit or explicit approval of whatever the client has done. Notice if you find yourself inclined to respond, “Oh, okay, I understand. Anyone would behave that way given the situation. I can see that you’re not all bad.” Or, by contrast, you may feel an urge to retort, “Are you kidding! Do you think that excuses your behavior?” You’re a well-trained clinician, so it’s not likely you’d say either out loud. See if you can notice, though, when a client asks of you something in the way of evaluation or possibly approval. These conversations mask 112

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themselves as description but contain a request for a social pass. Sadly, the request is foredoomed. In the case I describe above, the one about my marriage, neither your blame nor praise will mend my relationship with my wife. At best, you can provide me with a balm that will numb me enough to persist in this line for a little while. But the conversation will have only a modest sense of vitality and little means to effect valued living.

CATEGORIES VS. SPECIFICS Early in his career, Mark Williams did some lovely research in which he found that depressed individuals produced more categorical rather than specific memories as compared to nondepressed control subjects (Williams & Scott, 1988). Mind-y conversations tend to be far more categorical than specific. Aaron Beck had a tremendous sensitivity to this issue, although he didn’t describe it specifically in these terms. Beck’s cognitive errors are largely a checklist of varieties of categorical thinking. Overgeneralization, black and white thinking, and catastrophizing, for example, are all examples of categorical thinking. Even when specifics are described, they’re quickly rolled into categories—never, always, hopeless, and unbearable become fused categories that must themselves be managed somehow.

THE FAMILIAR (AKA THE OLD AND STINKY) The last of these common factors in mind-y conversations is that they’re frequently familiar in the extreme. If any of the above resonated with you at all, consider how long those conversations have been rumbling around in your head. There can be an endless repetitive quality to these conversations.

GETTING PAST CONTENT The contents of mind-y conversations can be very compelling. It’s worth noticing how much we want to either join in these conversations—taking one side or the other—or run away from them. (Both getting involved in mind-y conversations and fleeing them are, by the way, different topographical versions of the same response.) Can you think of times when you’ve engaged in either response? Was it helpful? In my own experience, I can’t remember a time when it was. Instead you’ll probably find it useful 113

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to let go of the words in a mind-y conversation for a moment and just listen intently to the physical qualities—the tone, pace, posture, and so forth—that the conversation presents.

The Quality of Speech in Conversations Words are incredibly captivating. In ACT, we call this capturing of attention fusion. It’s neither bad nor good. But fusion can sometimes cost us awareness of other things that are going on in our interactions with clients. Clients come to us with problems, and our part in the conversation is to discover the nature of the problem and to generate a solution. We typically go about this in a way that’s not a lot different from ordinary conversation, except that it’s typically more systematic. We’re trained to query some set of signs and symptoms. Is the person anxious? How long has this been going on? Are there situations that make it better or worse? On down the list we go. About the only time we’re trained to direct our attention to the process of speech is when we’re assessing for things like thought disorder. The way ordinary conversation works is that one person speaks and then the next person responds—back and forth we go. Watch yourself in ordinary conversations. We devote a certain amount of attention to the content of our conversational partner. Perhaps we try to work out where he’s going in the conversation. We devote the rest of our attention to generating a sensible response. Clinical conversations often proceed in the same way as ordinary conversations, except that we, the clinicians, bear the added burden of figuring out the nature and source of our clients’ problems. One of the main things I do when consulting on clinical work is to slow therapists down, to get them to let go of the content of what their clients have to say and see if they can hear something in the pace, pitch, and cadence of speech. Sometimes during experiential role play exercises at workshops, I listen to the room. It’s a good way to learn about the process of speaking because there are dozens of voices in the room, and it’s almost impossible for me to hear the exact content being spoken. I direct my attention instead to the process of speaking—listening for highs and lows, for the rise of pace, for tone of voice, for the fluidity of speech. I encourage you to try this yourself. Start listening to some of the rooms you inhabit. While at lunch, let your eyes go closed and listen to the restaurant. Let your attention move among the different sounds: the 114

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droning of the air-conditioning system, the clatter of the kitchen, the overall sound of the voices. Notice the most prominent sounds. Let your attention touch down lightly on the smallest sounds in the room. Listen to the space between the sounds. See if you can appreciate the sound of the room as a whole, as if it were a living thing. See if you can notice how different sounds protrude and poke at the edges of that whole. Are there rhythms, pulsings, repetitions? Do some sounds crowd others? Do some seem to intrude from without? Do some draw your attention away to some other task, to the past, to the future? Notice how your attention is drawn to individual voices and to what they’re saying. Notice to what extent you’re drawn to the content of speech, stretching out to pick up even an individual word. Our minds are hungry for those words, for that content. Appreciating the whole is not a job the mind will like. It’s too simple. The categorizing will satisfy it for a bit: dishes clattering, person speaking, door opening, and so on. But appreciating the soundscape of the room as a whole—there’s no problem to solve! What’s a mind to do? Mmm—content. Delicious! Given even a tiny bit of content, the mind can start to figure out what’s being said. Figuring out is a task worthy of the mind. As you notice yourself being drawn to content, see if you can gently let go of that content and notice how your experience of the whole room changed as you recognized words or sentences. Content can be like that. Once we get it, even a snippet of it, content focuses our attention and the wholeness of the experience drops away. When it does, let go just a bit more and come back to the room as a whole. Just appreciate the shape of the sounds in that room. Try this at staff meetings. Stop a moment in line at the grocery store. Try this in a place that seems quiet and notice that even those quiet places have their own subtle soundscape. Practice. Practice that gentle return to the whole. All of this practice, though interesting and lovely in its own way, is intended to help you achieve a certain sort of conversation: mindfulness for two. Slowing down and listening in this way will take you out of the stream of ordinary conversation. Ordinary conversational modes are strong and well-rehearsed behaviors, and we’re very likely to become absorbed in content when we engage in them. When we interact with one voice, that of the client, content is even more likely to capture our attention. Note that the goal here is not merely to ignore content, certainly not by force of will. The thing to work toward is an appreciation of content in its place within the whole rather than having it substitute for the whole—along with the ability to discriminate what’s going on in conversation beyond content. 115

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Recognizing Vocal Patterns Sometimes the easiest way to hear your client’s patterning and your own is to listen to a recording of one of your sessions. This helps because it takes the social cues for response off the table. You’ll find it useful to develop an ear for speech as process at the level of the individual speaker and of the interaction between two individuals in conversation. Pitch, pace, and cadence are always running in the background. They organize content, but they typically go unnoticed or at least unappreciated. You’ll want to get an ear for the flow and texture of speech so that you can listen for the emergence of patterns common in behavior under aversive control—patterns that are relatively narrow, relatively inflexible, and relatively insensitive to contextual control. In order to hear variation in vocal patterns, you’ll need to acquire an ear for patterning independent of content. Almost the only people who have such an ear are voice instructors and musicians, though sometimes preachers and other orators develop this capacity for hearing. Most of us leave this capacity undeveloped as we content ourselves with the content of what we hear.

LISTEN FOR VOICE QUALITY Start your journey into the non-content side of speech by listening for the relative fluidity of speech. Sometimes voice has a soft and pliable quality. Sometimes it seems to have sharp edges. There is, of course, variability among clients, but you’ll hear variability within individuals too. Listen for a strained, constricted, choked quality of voice. If the person is being squeezed into a relatively narrow pattern of behavior, you’ll often hear that reflected in her voice. You’ll also recognize urgency in people’s voices. It may sound like pleading, whining, complaining, demanding, or being pressured. All of these variations will share a certain imperative quality. There’s something, perhaps ambiguous, that must be done, solved, figured out before anything else can happen. If you’re focused on content, you are very likely to miss this urgency. But you might hear it in someone’s voice if he’s speaking in a foreign language, an experience I’ve had more than once.

LISTEN FOR PACE Listen for your client’s pace in casual conversation. Note the quality of the patter in the waiting room, in the causal beginnings and endings of session. What’s your client’s pace when the conversation is easy? How 116

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does it change when the topic gets hard? Listen for patterns in pace that might be indicative of a response to threat. Sometimes this will take the form of an almost staccato series of complaints. Your clients may at times proceed at a pace that’s almost tentative. They may speak in partial sentences or with long hesitations. Another common pattern in pacing is a somewhat rapid pace, as if the conversation is urgently attempting to get somewhere or away from something.

LISTEN FOR CADENCE And finally, listen for the cadence of a client’s speech. You can practice this most easily with an audio recording. On your own, listen to the recording and see if you can’t duplicate the cadence without using any words, just sounds. Okay, you will feel goofy doing this, but take a couple of different client recordings and see if you can hum two distinctly different songs—a bit like humming a tune. You can also try just tapping your hand or foot as if you’re tapping along to a song. See if you can notice a patterning in that cadence.

REPETITIONS IN CONTENT As I mentioned in the section above on mind-y conversations, you’ll often find content that will be repeated again and again in session. Watch for the emergence and reemergence of these topics and patterns of speech. Watch for the relative inflexibility of these patterns once they emerge.

Recognizing Patterns in Physical Presence Breath typically goes unnoticed. But breath is a physiological function that’s quite responsive to conditions of abundance on the one hand and conditions involving threat and ambiguity on the other. Is breath smooth, slow, and regular? Does the client stop breathing at all during certain moments? Does breath come in gasps? Does the person cough? Is breath choked or constrained in any way? Is it deep or shallow?

REPETITIVE MOVEMENTS Watch for things like nail-biting, hand-wringing, shifting in the chair, fidgeting, foot tapping, clenching of jaws, and other small �behavioral �stereotypies. Are there times when these are more pronounced, intense, or driven? 117

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POSTURE Often when people are in the throes of strong negative emotion, their gaze will be downcast, shoulders hunched, and arms and legs crossed and held close. There are a lot of social contingencies that cause people to disguise and otherwise downplay the experience of negative emotion. One way to accomplish this is to get small or to turn away slightly. Gaze in particular is socially relevant. The social convention when weeping is often for them to look away, to apologize, and, as quickly as possible, to attempt to contain that display.

WATCH THE EYES The poets say that the eyes are the mirrors of the soul. It’s much easier to manage what one does with one’s feet and hands than with facial expression of emotion. This is especially true of the eyes. Sometimes the most transient touch of emotion will move across a person’s eyes while little else makes emotion apparent. A momentary watering of the eyes, a slight heightening of reflectivity, may be the only apparent trace of emotion you can see. You needn’t know what has elicited the reaction to see that the reaction has occurred. A simple slowing down around such moments can sometimes reveal both to you and to your client the depth of experience that underlies that upwelling.

Emotional Tone Note the emotional tone the client brings to the session. Most frequently the emotional tone will have an anxious or depressive quality. But it’s also not uncommon to see an overly casual presentation—sort of an “I’m fine” posture. The critical issue for you to pay attention to is not the tone as such, but instead the pattern and the relative flexibility you observe in that pattern.

Transitions and Relative Flexibility in All of the Above Above all else, listen for and learn to precipitate transitions in vocal patterns, including the patterns described in the section above on mind-y conversations. The justification for watching these things very closely is that, when you do so, you’ll be prepared to see transitions in behavior. 118

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Here you should be concerned both with transitions to and from relatively narrow patterns. When these patterns change, something in your client’s psychological world just changed—remember, this is behavioral patterning in a context. The thing that makes human behavior far trickier to monitor than that of nonhuman species is that the transitions in context among nonhumans are often signaled by apparent and significant changes in the immediately observable world. Among humans, it can be more difficult to see what changed. A simple word can call up a rich history. An image can precipitate a person’s worst and most private fears. Very, very often the precipitants will not be at all obvious. However, if we can see the transition in the patterning of response, we can know where to begin looking closely—at the cusp of those transitions—for the relevant shifts in context.

THE EMERGENCE OF PSYCHOLOGICAL FLEXIBILITY The most obvious place to see these transitions is in a traditional exposure-Â�based session. When I train people to do exposure-based treatment, I like to suggest that a really artful exposure session has a life cycle. When the person is first exposed to the feared object, arousal goes up and an inclination to avoid in various ways rises with arousal. As the exposure session proceeds, flexibility begins to emerge. There’s a point that we reach in an exposure session where there’s a sense that we’ve done our work. When I was a boy on my grandfather’s farm, my father and uncles would cut hay in the summer. The hay would lie in the fields until it dried in long, yellow heaps. Then a great machine would chug through the field, gobbling up the loose hay and leaving hundreds of bales in its wake. The farmhands would pull the tractor out with a trailer behind it, and they would spend the day bucking bales of hay onto the back of the trailer. At the end of the day, there would a sense of release and accomplishment. You could look out over those fields and see that stubble of cut hay, and when you looked in the barn, it was full to the roof. There was a sort of weariness in those moments that was a good weariness. Some kinds of weariness leave us feeling lifeless, but other kinds of weariness leave us feeling quite alive and connected. A good exposure session is like that. You feel tired, but it’s a good tired. My dear friend Philippe 119

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Vuille, at the end of a long, hard workshop, told me of a French expression that captures this sense beautifully: la bonne fatigue. Watch your client when she is anxious in anticipation of an exposure session. You can see vividly the narrowing, inflexibility, and context insensitivity in behavioral patterning that emerges when the phobic object is presented. You will be able to observe most if not all of the indicators described above in a session such as this. Ask your client to speak, and you’ll hear her choked voice and shallow breath, the stereotypy in her speech. You’ll also see how difficult it is to engage her in conversation. Her exclusive sensitivity to the exposure will be pronounced. Emotionally, you’ll see little flexibility. Her facial expression will be constrained and rigid. At the end of a good session, you’ll begin to see the complement to that as more flexible patterns of behavior emerge. In a certain sense, all acceptance and defusion work is kin to exposure. All three involve events that generate narrowness and inflexibility in responding and insensitivity to shifts in context, except shifts directly relevant to escape. As you bring your clients into the present moment with fused and avoided content, as you slow them down and gently coach their kind and careful attention, you’ll know that those events are losing some of their ability to control behavior as the pattern of behavior becomes more flexible. You’ll see it and hear it right before your eyes. Listen to the voice. You’ll hear a softening and increase in the flexibility of tone. The voice will take on a more rolling and fluid quality. You’ll find that it becomes easier to set the pace of the interaction. Your client will begin to respond to your prompts to stop, notice, and then to move on. Her ability to appreciate values connected to vulnerabilities will begin to emerge. In terms of physical presence, you’ll begin to see her shoulders drop. Her nervous movements will begin to damp down. Her breath will become less strained, easier, more gentle. Her bodily movements will become more fluid. Emotionally, watch and you’ll see your client’s capacity to move among different felt states increase. The end of a really solid acceptance and defusion session will leave your client able to move between tearful sadness and easy laughter. It’s odd: if you ask a person if he can stop and notice how frightened or sad he had been at the beginning of the session, he’ll be readily able to do so. He’ll somehow be in better contact with himself as frightened, distressed, or grieving, but at the same time, he’ll be more hopeful, joyful, and vital. Again, what you’ll see is a sort of rolling flexibility in emotional tone. 120

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Flexibility in these domains is also marked by sensitivity to context. You can see this when you make probes. For example, after a session, you can ask about entirely unrelated values and you may find that your client is better able to bring attention to bear in that domain and then to shift attention back to the work done in the session.

THE DANCE BETWEEN MINDFULNESS AND CHANGE Most ACT protocols are laid out in a somewhat linear fashion. In the original ACT book (Hayes et al., 1999), the treatment begins with creative hopelessness and close experiential contact with unworkablility, and then moves on to an exploration of the control agenda as an unworkable metastrategy. From there, it proceeds to defusing language, discovering self, then finally to values and commitment. Books are structured like that—they have a beginning, middle, and end. The pages and chapters are numbered serially. Of course, ACT can be carried out in this general order, but this ordering has caused some to imagine that it must be carried out in that order. Whether this is so or not is an entirely open empirical question. Worse still, the structure has led some to imagine that once we’ve worked through avoidance and fusion, we’re ready move on to values and needn’t worry too much about avoidance and fusion while doing values work. Taking this approach can be very frustrating because it often leads to great clarity about values but little movement. Homework assignments go undone. Commitments are postponed. Other troubles that are brought to therapy seem to crowd out the values work. Very often this lack of movement, this stuckness, this inflexibility is the result of the reemergence of fusion and avoidance. There’s no value that isn’t complemented by a vulnerability. One of the easiest ways to generate fusion and avoidance is to start talking about values, especially where a person has experienced serious losses and disconnection. Even worse, begin talking about making commitments in those areas! Calling to mind a value often makes immediately present how lacking we are in that domain. For example, when a client begins valuing being a parent, the very next thing that happens is an awareness of all the ways that he has failed at that. At this point, we see behavior become narrow and inflexible, and we turn back to acceptance, defusion, and mindfulness interventions. 121

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But if not in the order described in an ACT book, what order? I myself tend to be quite flexible in the ordering of the work. In principle, the six ACT processes described in the hexaflex are not independent. These are six lenses or facets through which we can look at a one whole person and one whole life. On a theoretical level, I expect that we could, in principle, start anywhere on the hexaflex. In practice, I tend to start with a humble and gentle version of a values assessment. I like to start with a sense of the direction clients would take in their lives if they could. This isn’t always possible. Sometimes people come in so distressed, so mired in suffering, so wrapped in a story of limitation, so fused, avoidant, and inflexible that any discussion of valued directions is impossible. In such cases, the only real way in is to settle into the room. As I proposed in the first paragraphs of this chapter, we need to meet our clients just where they are. If that means running a hundred miles an hour, it falls to us to get up to speed. And having met them at a dead run, we begin to gently engage in pace setting and bringing them gently into the present moment. The interventions called for in the face of very strong fusion and avoidance are present-moment focus, acceptance, defusion, and settling into a sense of self-as-context. As present-moment focused, mindfulness, acceptance, and defusion interventions alter the context, behavioral flexibility emerges and, with it, increased sensitivity to context, including that aspect of context we call consequences. As flexibility appears, clients can be responsive to manipulations of operant contingencies and we can turn our focus back to values, behavioral activation, and committed action. These interventions give clients the opportunity to expand operant repertoires and pursue changes to behavior, the appetitive consequences of which are in the behaviors themselves. This transition from strong antecedent aversive control to appetitive consequential control isn’t a one-way, one-time shift. Rather, behavior will move back and forth between aversive and appetitive control. You can respond to these shifts, shaping both as they occur in the moment. There’s a dynamic quality to such work. When we begin to see the telltale signs of psychological inflexibility, we slow down and move to mindfulness and acceptance. When signs of flexibility emerge, we move into values and committed action. Even while doing values and commitment work that’s proceeding well, it’s worthwhile to stop for mindful moments. In doing so, we actively shape the capacity to move with intention, on purpose, from activity to activity. 122

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Finally, perhaps the best place for us to look for these transitions is in our own experience in the moment during sessions. Human behavior is reciprocal, and when we feel our own behavior become narrow and inflexible, it’s likely that the client is experiencing the same restrictions. Even if it’s not the same aversive to which we’re responding, we don’t need to know what’s generating that inflexibility in the client in order to intervene appropriately. In the next chapter, we’ll examine the ways that we therapists lose contact with the preset moment and, of course, how we can find the way back.

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The things we look for as we sit with clients are all data. A certain narrowing and inflexibility in repertoire tell us that the client has entered scary territory. The same principles that apply to clients apply to therapists. Bob Kohlenberg, founder of functional analytic psychotherapy, made a great contribution to my training by teaching me that everything that happens inside your skin in the therapy room is data too (Kohlenberg & Tsai, 1991). And my mentor, Steve Hayes, who was at the center of my training as a scientist, taught me that data is always your friend.

DATA IS ALWAYS YOUR FRIEND, EVEN WHEN IT’S NOT FRIENDLY What Steve meant was that, when data don’t comport with our analysis, we tend to turn away from them. But negative findings help tell us about limiting cases. They tell us what’s wrong with the study or with our assessments, and—if we’re very, very fortunate—sometimes data can tell us what’s wrong with our theory. This can be painful news, but if we’re serious about doing our jobs as clinicians and researchers right, it’s news we want to get.

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When I was learning to do therapy, a lot of things showed up inside my skin that were decidedly unfriendly data. I had thoughts and feelings about myself. I felt stupid and incompetent. I thought I was a fraud. I had thoughts about the clumsiness of my interventions. Some things my clients said hurt or terrified me, leading me to terrible self-doubt:

• I have no idea what to do with this guy. • Why does she keep doing that over and over? • I don’t have any idea what to do. I feel completely hopeless. Sometimes I felt entirely uncharitable things about my clients:

• This person is boring. • I really don’t like this guy. • Will this hour ever end! These thoughts and feelings were very unwelcome guests at the party. I tried to kick them out, but they returned again and again. And while I was busy trying to kick out those disturbing thoughts and feelings, I was less available to my clients. What Bob suggested, in his 1991 book Functional Analytic Psycho­ therapy, was to get interested in those reactions, to take time with them, and in particular to explore the meaning of those reactions in terms of the relationship between therapist and client. Bob taught me to slow down and pay attention to those reactions. He showed me that those reactions had something to say to me, if I would just take a moment to listen. ACT has certainly internalized many of Bob’s sensibilities, and these are very significant to my purpose in Mindfulness for Two, since many of these difficult experiences—really our time spent managing them—take us away from the present moment. We get busy and lose the only moment we actually have. I’m not talking about imagined moments, the befores and laters. Instead I mean the very moment we inhabit with our clients right there in that room, a moment we can either share or neglect.

PHYSICIAN, HEAL THYSELF From my introductory comments, you’ve undoubtedly realized that the focus in this chapter will be on the therapist. We’ll examine some of the 126

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same issues we looked at in chapter 5 but from the inside out. That is, we’ll explore how can you detect and understand disconnection from the present moment when you’re the one who’s disconnected. We’ll look at the most common manifestations of present-moment process failure that you’re likely to notice in yourself—what precipitates them, how to identify them, and how to intervene. The process issues from the therapist’s side of the therapeutic interaction don’t differ in kind from the ones on the client’s side. One of the radical things about ACT, and really about behavior analysis, is that you don’t need separate sets of principles to understand client and therapist behavior. The same principles apply to both. The best way to learn to make any discrimination is through multiple exemplar training, which is a very technical way of saying that, if you want to learn a basic principle, watch for it wherever it applies. It’s a mistake to use a principle to understand client behavior and then ignore what it might be able to tell you about your own. It’s easy for us to assume that if clients are more present, they’re more likely to profit from their exchanges with the world and the people in it. If they’re to learn, change, and develop, we take for granted that they’ll be aided by an increased ability to focus attention on their activities. If learning mindfulness is a priority, we practice these skills with them in session. If this is true for them, though, it’s equally true for us. By increasing our own ability to focus on what’s happening in the present moment, we can sharpen our clinical skills. Our interaction with clients is a sort of dance. We may lead, but we need to lead with flexibility, including the flexibility to know when to give over the lead. We need to determine when it’s time to intervene and when we’ll accomplish more by sitting back and listening. Sometimes we need to speed things up; at other times, slowing down is what the situation demands. In all of these cases, studied and practiced attention to the present moment is one of our greatest clinical resources. I’ve described the client’s behavior as being in dynamic relation with the environment. Client behavior is an evolving stream of activity—a living, breathing thing. Our behavior is the same. For us, the client is the central element in the environment of our sessions. To fulfill our mission in the therapy room—to facilitate our clients’ change and growth—we need to make close contact with them, moment by moment. Like them, we’ll profit the most from our exchange if we’re fully present to it.

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GETTING STARTED: WATCHING YOURSELF All of the issues discussed in the last chapter, though applied there to clients, also pertain to you. If you have audio recordings or, better still, video recordings of your sessions, I recommend turning your attention to your own behaviors with the same eyes you turn toward your clients. If you don’t have access to recordings of your own work, you can practice on some of the videos you’ll find on the DVD-ROM that comes with this book. Watch for things like pitch and pace. Watch for narrowing of behavior, insensitive persistence, posture, affective inflexibility, and all the rest. For brevity’s sake, I won’t repeat the last chapter here; rather, I’ll augment it. With clients, we’re limited to what we see and hear and what they report. We don’t have direct access to their great interior world. You do have direct access to your interior world. Ironically, you have somewhat less access to an exterior view of your own patterns of responding. This makes listening to audio and watching video all the more valuable. In cultivating therapeutic responsiveness to the emergence of client inflexibility, you need to be able to see and hear the outward manifestations of inflexibility. You need to become a connoisseur of the minutiae, the subtleties of inflexibility. To get at this from your side, though, you need a different skill set. Watching video or listening to audio is very instructive, but it’s only really instructive after the fact, or perhaps in the present moment in a supervision or consulting group. However, in session, your most powerful tool is careful, moment-by-moment awareness of your own interiority. This ought not be confused with the domination of that awareness—fusion with your own reactivity. Below we’ll deal with those things you can access that no one else can see directly. Bear in mind as you read that what you’re looking for are those moments when you withdraw from the present moment and lose flexibility and, in that loss, lose your client. Disconcerting though these discoveries may be, remember that they are invaluable sources of data.

SAVANNA MIND, DANGER, AND AMBIGUITY Recall the gift of this lovely mind that grew up on the savanna. It kept us safe out there in a world of lions and tigers and bears. It gave us the great gift of a relatively narrow and relatively inflexible repertoire that was just the tool we needed to survive those harsh environs. Unfortunately, 128

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we’re capable of that narrow and inflexible repertoire even when there’s nothing hungry nearby with sharp teeth and claws. What generates that narrow and inflexible repertoire in therapists? I would propose that it’s an alarmingly high prevalence of “clientophobia” among therapists. If you work with easy clients, this probably isn’t an issue for you. If your clients come in, present a few problems, seek a bit of counsel and open discussion, then go home and get their lives on track, you can skip this chapter. Or, if you’re one of those supremely confident therapists and have a persistently positive view of your own work, this chapter probably doesn’t apply. But if you’re like me and often have a sense of working frighteningly above your capacity, or if your clients are like my clients, you might want to stick around.

FUSION AND AVOIDANCE IN THE FACE OF HARD HISTORIES There are many, many ways that clients can become aversives for therapists. The most obvious way is that they often come to us with incredible stories of pain and loss. Marriages break up. People go years without experiencing the kind caress of another human being. Children are abused by the people who are supposed to love and care for them. People suffer downs that leave them in bed for weeks and anxieties that make a trap of their homes and strangers of their loved ones. Sometimes we don’t like really difficult clients. Sometimes they make it very hard to like them. They insult us and question our integrity: “You’re just doing your job,” they say, or, “You don’t really care about me.” When we really like them, we experience lack of progress or relapse as terrific pain. In an important way, the more we like the client, the more painful his losses are. I treated a woman years ago who had suffered the most horrific history of childhood sexual abuse I’ve ever heard. She’d been sexually abused by both parents, and there had been a complete silence around the abuse for nearly thirty years. She didn’t begin to disclose this history to me until a couple of months into treatment. In fact, she denied any significant problems growing up in response to my first probes. Treatment began with a simple question about whether she should stay in college or return home to care for her ailing mother. Only over time did she begin to reveal her level of selfloathing, self-injury, and suicidality. She cut and burned herself and hit 129

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herself on the hands and feet with a small hammer. On one occasion, she reported to me that she had carved a word into her own thigh. Later still, she disclosed the childhood trauma. Over the course of three years of treatment, we came a long way from that initial, mild, college-student presenting problem. In session, the work was so painful at times that she would literally howl like an injured animal. The sound could be heard all over the clinic. And, like an injured animal, she would frequently lash out. Once, a year or so into treatment, she was clearly angry at me. I made what was, in retrospect, a rather ham-handed interpretation suggesting that she was treating me as she treated her father. She responded, “Oh, no. It’s worse with you. I expected it from him.” Clients like this can teach us something valuable. When we sit with clients who are in such pain that cutting themselves provides a sort of relief, we don’t have to wonder why they’re so frequently referred, overmedicated, and hospitalized. Sitting with someone in that much pain is painful. These clients are often abandoned by family, friends, lovers, and, too frequently, by therapists. It’s very hard not to. It’s hard to sit with pain, and it’s hard to sit with slow or no progress. And when we do leave these folks, we confirm their worst fears and most certain self-evaluation: that they are fundamentally flawed and destined to die alone and unloved. Even when we don’t leave them entirely, we leave them in smaller ways right there in the room. The pain inherent in such clients is often compounded by wonderful intelligence, creativity, humor, and passion. Seeing that capacity unrealized makes the work doubly hard and our own failings doubly painful. Have you failed some of these clients? Do you know something about that sigh of relief as you hand them off to another professional? If there’s an afterlife, I suppose that there will be special dispensations for people willing to sit with someone in that kind of pain. Marsha Linehan, founder of dialetical behavior therapy, has my undying respect for her devotion to work with folks with this sort of pain. I sat with the woman I described for three years, so maybe there is some small Â�dispensation for me.

Noticing Process with Hard Histories Even just reading the words “noticing process with hard histories,” you may feel a bit defensive. Do you find yourself saying, “Yes, but…”? 130

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• Yes, but I’m not running a DBT practice. • Yes, but I don’t have the appropriate training for that work. • Yes, but my practice setting isn’t appropriate for that level of care.

Of course, all of these things may well be true, but if you found yourself feeling defensive, notice that you’re defending yourself again ink marks on a piece of paper. What’s there to be argued with? I’m not asking or telling you whom you should or should not see. That wouldn’t be my place. But it’s worth noticing that even the mention of such clients can sometimes move us to raise walls to protect ourselves.

Fusion with Solutions Our more challenging clients churn up all manner of fear and selfdoubt in us—at least in me. Is it just me? This is particularly painful when at least some things they need to do are obvious. It was very clear with the client I described above that she needed to stop injuring herself and to keep her distance from a very toxic family. Isn’t it obvious that the chronic alcoholic client needs to stop drinking? For the depressed person who hides in his house with the shades drawn day after day, isn’t it clear that nothing can change without him getting up and out into the world? We don’t like being so near a solution and having it be entirely unavailable. It’s all too easy to get stuck on these solutions—what I call “solution fusion.” We can keep our eyes so fixed on those solutions that what’s happening in the room can become elusive.

Fusion with ACT-Consistent Solutions A subtler, more problematic version of solution fusion can occur when the solution you’re aiming at is ACT consistent. You see some bit of difficult material that you’re sure the client needs to accept. Some story she’s relating just screams self-as-content. Or he remains steadfastly rooted in the past or the future, disregarding whatever it is that’s actually going on right now. Sure, we subscribe to this treatment model—we think it does a pretty amazing job. But having the ACT seal of approval on the side of it doesn’t mean that we should seize it tightly and focus 131

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on it to the dereliction of everything else in the room. And it certainly doesn’t mean we need to coerce our clients into accepting it. Consider the rape victim who needs to accept thoughts and emotions that arise in intimate contexts, or even at their mention. If we look it into the person’s life, the cost of avoidance might be very apparent. If we look at what’s happening, we may see avoidance right in the session. When the topic is raised, the client defers the discussion to a later time, professes incapacity, professes hopelessness, professes confusion, and so forth. We can literally pinpoint the areas of her life where acceptance would lead to better things. But what if she’s simply not capable of being accepting at this moment? One of my most common errors doing ACT is to confuse what the client needs to do with what I think the client needs to do. When I’m right, the situation is worse. When my conceptualization of the problem is correct, I’m even more likely to become fused with my solution and to try to convince, explain, and, on my worst days, bully my client toward acceptance. But acceptance that’s forced upon a person isn’t acceptance at all. I’ve just added another layer of aversive control to a client already working in painful world. It’s worth noting the difference between being correct and being right. We may well be correct in our analysis, but wrong in our relationship with the client and the spirit of the work. Remember, ACT isn’t about exchanging an evil tyrant for a benevolent tyrant. It’s about freeing people from tyranny. The most frequent complaint I hear from ACT therapists is that their clients simply will not move on stated values or that they refuse to do acceptance work even though they “know” that it needs to be done. If you find yourself in such a situation, notice your own experience in session. Do you find yourself exhausted afterward? And here I don’t mean la bonne fatigue. This is the sort of tired that makes you rethink your career choice. If you look into those sessions, can you find small ways that you quit your job without even leaving the session? Even just for a moment?

SITTING INSIDE IRRESOLUTION: THANK YOU, MESSRS. CAMUS AND ELIOT If you want to see how fused we can be with solutions, try the little exercise below. The exercise involves either eating or not eating a meal and 132

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spending some time with not knowing which. You should only try this if you’re one of the fortunate in the world who isn’t one meal away from starvation. If you want to see how minds work, here’s your chance. It’s a little unfair to minds, so you have to be willing to tease your mind a bit. But considering the way it has deviled you, turnabout seems fair play. So far, I’ve never heard of a mind dying from this, so you don’t have to worry about your mind’s tantrum.

EXERCISE: To Eat or Not to Eat Prepare a meal. Sit down at the table, good and hungry. Dish up a plate. Pour a favorite beverage. Pick up your knife and fork. Smell the food. Move your knife and fork toward the food. And then just stop—linger a moment. Cut a bite and pick it up with your fork. Then just stop again. Now raise it toward your mouth and stop at the cusp right between eating and not eating. If you find yourself not eating, gently move in tiny increments toward eating, but don’t eat. Linger right there at the cusp. Find that place right at the tipping point between eating and not eating. Your mind won’t like this. It will tell you that there is no such thing as the place between eating and not eating. If the food isn’t in your mouth, then you aren’t eating! it will tell you. If it’s in your mouth, then you are eating. It is that simple, it will insist. If your mind delivers this objection, please thank your mind for that observation and come back again to that place right on the very cusp of eating and not eating. (See if you can notice that the mind makes a pretty strenuous objection to something that doesn’t exist. I mean, if it doesn’t exist, what is the trouble? Right? Goodness! Teasing minds is so much fun.) Choose to not know whether you will eat the meal or not. Again, your mind will object. It may even say, To hell with you! We’re going to eat! And thank your mind for that. Just sit in that place in between. Fine, we won’t eat then! Watch what shows up in your internal world:

• But the food is getting cold! • Okay, how long do I need to do this? • This is stupid. • This is wasteful. • What’s the point? 133

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And then just sit. Let yourself go quiet. Let yourself come to your own breath. Settle into your own body, into what it feels like to sit in your own skin. And watch the objections rise up. Notice your own body. Notice how intolerant you are of problems (I’m hungry) and a solution so close (a meal before you). In the end, either eat the meal or wrap it up for later and don’t eat. Let whether you eat or not be undetermined until you’re finished with the exercise. (And notice the huge sigh of relief your mind makes when you finally choose.) Let me further encourage you to leave the length of time spent at that cusp undetermined. Notice all of the reactions that well up as you wonder how long you’ll wait or if you will eat at all. Notice how much you want to resolve that before the exercise is over. Notice how insistent your mind is in the face of the undetermined. Notice how intolerant your mind is of the unknown, even when the unknown is as trivial as whether or not you will eat a single meal.

If you actually do this exercise, and perhaps even if you don’t, notice yourself objecting to me. Perhaps you’re writing a story in your head right now about why you don’t need to actually do this. Or better still, you tell yourself, Oh yes, very good, I will do that…later. Minds don’t like the places in between. This is what T. S. Eliot was speaking of as “the still point.” Camus likewise knew this place as waterless deserts where thought reaches its confines. At that last crossroad where thought hesitates, many men have arrived and even the humblest. They then abdicated that which was most precious to them, their life. Others, princes of the mind, abdicated likewise, but they initiated the suicide of their thought in its purest revolt. The real effort is to stay there, rather, in so far as it is possible, and to examine closely the odd vegetation of those distant regions. Tenacity and acumen are privileged spectators in this inhuman show in which absurdity, hope, and death carry on their dialogue (1955, 9–10). You can use the little exercise above to take you to a place that minds will assert does not exist—that still point between doing and not doing. As Camus suggests, your inclinations will be to jump. You’ll want to jump in (and eat). Or you’ll want to jump out, to retreat (and leave the table). Or perhaps you’ll find your mind wandering to other matters—an endless stream of befores and afters. 134

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See if you can reflect back on the exercise and notice the relationship between that exercise and your work with clients. Isn’t it often our intolerance of the unresolved that drives us to act or retreat? And don’t we see the same in our clients? Lurching ahead on a new effort to “get it together” and by turns retreating again into the house, into the bottle, into some respite from uncertainty? Moving in either direction can function as a means to avoid uncertainty. And, looking a bit further still, see if this uncertainty isn’t present in every truly significant value in your life. Consider getting married. How will that turn out? Consider a career change. How will that turn out? Consider having children. How will that turn out? And, working with clients, how do we bind our anxiety when that world gets uncertain? Do we know in advance how that will go? Uncertainty lies all about us. We can’t eliminate it, but we can blind ourselves to it. But what if it’s the case that there’s no way to blind ourselves to uncertainty that doesn’t also blind us to our values? We can hide out in certainty, and sometimes we will settle for the illusion of control. But, in doing so, the beasts don’t go away. We just can’t see them anymore. The good news is that for most of us, since leaving the savanna, the beasts are mostly the psychological variety. I’ve never been eaten in my office, though I’ve often feared it. Camus knew this still place between action and inaction, and he knew also its remarkable bounty. What freedom would you possess if you could sit in the face of ambiguity and uncertainty without having to act? If you could allow yourself to settle in and become intimate with “the odd vegetation of those distant regions”? Where terror lives, there is also bounty. We don’t like these places that we don’t know, but it’s in precisely these foreign places that possibility lives. If there were something possible for you in those distant regions, would you travel there with me? And would you travel there with your clients?

THERAPIST FUSION AND AVOIDANCE There’s reciprocity in session between therapist and client. The reason I use an extremely difficult case to illustrate this is that the best way to find high levels of therapist fusion and avoidance is to look for high levels of client fusion and avoidance. If you want to find therapists who have lost contact with the present moment and who are thoroughly fused with some version of self-as-content, look for clients who have little or no contact with the present moment and zero sense of themselves 135

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Â� independent of an entirely fused version of who they are and what the world holds for them. In the last chapter we looked for signs of fusion and avoidance in clients, and we’ll now look for these signs in ourselves. We’ll use the self-as-laboratory. The first rule is look to your clients. If they look very, very stuck, check yourself out. You’re likely to find a rich vein of avoidance and fusion that can be mined. You’ll not likely find this data with a smile on your face. As I suggested, the data is always your friend, but often it does not look the least bit friendly. Now for a small pause for values and commitment in the face of fusion and avoidance: Let’s have a show of hands. Everyone reading, hold up your hand if you’d like to discover huge hidden hoards of fusion and avoidance inside your own skin. Go ahead. Raise your hand. You know you want to be rich in fusion and avoidance. No? Not so much? Why? Well, because if we found a huge hoard of fusion and avoidance, that would be bad. That would be a problem. And then we would have to find a solution. And so we turn away. And here we are, you and me and clinicians everywhere, all of us together, having turned away a hundred times. Why are we here? Take a moment and think about a client you’ve had whom you really, really wanted to help, but whom you lost—a client who just never moved, maybe one who left and you wonder about from time to time. Take a moment and let your eyes close and let yourself see her face. Let yourself see where she might be, right at this moment. I beg you, let your eyes close and let yourself see your client’s face. See if in that face you can see the losses she’s suffered and the seeds of losses to come. Can you, with me, just take a moment to breathe that sadness in and out like air? Can we, in honor of the fallen, let go of any resistance to seeing them and the costs they paid? I promise that I’m doing so right now as I write this. I can see the faces. The lost ones. The ones who sat across from me carrying some small sliver of hope that I could help. And I can see their faces as they slipped from my grasp. I can see them falling away. Can you? Will you? Will you let those losses be your touchstone as you open yourself up to hard material, to the unfriendly data that are nevertheless your friends? Can we recommit to those folks right now, as if to say, “I will not let your loss be forgotten? I will keep you close as I do my work, to remind me of why I would do such a hard thing as to look within, to remind me why I would do such a hard thing as to sit gently in the face of ambiguity and uncertainty.”

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What Therapists Think and Feel and What They Do To some extent, probably all clients, but certainly our more difficult clients, precipitate hard experiences for us. They present us with impossible circumstances. Or they present us with circumstances where the solution is painfully obvious both to them and to us, but the solution isn’t implemented. They present a nonstop stream of problems and we can hardly catch our breath. We seem to be working productively on one problem and the client switches to another. We have a good session and he cancels the next two. He lashes out and fails to comply, or he complies with such slavishness that it breaks our hearts. All of these circumstances can occur for us as problems to be solved. And, in a certain sense, they are. We tend to be very responsive to problems. When confronted by them, we experience a narrowing effect on our repertoire. Sometimes our focus on problems causes us to lose the whole, to lose what else is available in those moments. We become fused with the problem, fused with our reactions to the problem, and fused with our solutions. Or, if we find no solutions, we become fused with our evaluations of that failure and try to solve the no-solution problem. All of these layers and layers of fusion and problem solving steal these moments from us and from the clients we serve.

How to Detect a Mind-y Conversation— The Therapist Version Our clients have mind-y conversations with us and with themselves. They live out their lives inside these conversations about limitation. And so do we. We don’t need clients in order to have mind-y conversations. However, our clients will certainly precipitate mind-y conversations both in us and with us. If we are to shift from conversations that specify the limits of living to conversations that contain life and possibility, we first need to be able to discriminate one from the other. Below are variations on mind-y conversations discussed in chapter 5. Here we focus on the particulars of mind-y conversations often precipitated by our interactions with clients. Since mindiness is mindiness, and we walked through these from the client perspective in the last chapter, I’m going to whip through these. But do pause and reflect if anything you read below strikes a chord with you.

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COMPARISON AND EVALUATION Do you find yourself complaining to yourself or to colleagues about certain clients? Do you find yourself evaluating your performance as a therapist with some clients or perhaps changing to a different sort of client or to a different treatment setting? Do you find that some clients occasion a lot of thought about whether you even want to be a therapist?

COMPLEXITY, BUSYNESS, AND CONFUSION Do you find yourself confused in session, perhaps struggling to keep the issues straight or striving to find your way as your client lurches from problem to problem? Do you find yourself at a loss with respect to the reason the client is even in therapy? Do you feel a sense of confusion about what to do next? Do you feel as if there are a lot of details that you need to keep track of?

STATEMENTS CONJOINED WITH “BUT” Do you remember the section on the use of “but” from chapter 5? Recall that there is a negating quality that this conjunction introduces into the conversation. Ask yourself if a lot of your conversations with yourself, your colleagues, or your clients include statements of the following flavor:

• I’d like to help this person, but… • Sure, it would be great if I could listen to that kind of thing all day, but…

• I know this sort of thing is hard for you, but… As is the case for our clients, when we find ourselves spouting these kinds of “but” formulations, there’s a better than fair chance that fusion and avoidance—and thus a break from mindful contact with the present moment—are somewhere in the picture.

ADVERSARIAL POSTURING AND SIDE TAKING Do you find yourself trying to convince your client of something— what she needs to accept or to do? This attempt to convince might be overt, but it might also be quite covert as you try to nudge her toward a place you know she needs to go. Or, by contrast, do you find yourself certain about a sense of direction but silenced because you know your 138

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client won’t go in that direction? What is the quality of that experience as you sit in the room not saying what you want to say when not saying is exhausting or demoralizing? Does your interaction have the feel of an endless tug-of-war?

STRONG FUTURE OR PAST ORIENTATION Do some clients cause you to persistently think about where you went wrong with them? Do you experience a sense of hopelessness about the future—for them, for your work together?

STRONG PROBLEM-SOLVING ORIENTATION Of course there’s nothing inherently wrong with problem solving. But we will want to know whether it is under reasonably flexible control versus narrow and inflexible stimulus control. How can we know? This is the math-problem-versus-sunset issue discussed in chapter 1. Sometimes you can find out just by pausing and asking yourself this question: Is this client a math problem or a sunset?

EXERCISE: Considering Your Clients Make a list of all of your clients. Take a bit of undisturbed time and slowly go over your list, pausing and closing your eyes a moment for each client, allowing yourself to see this client, allowing yourself to see the client moving around in the world he inhabits. Then ask the question: Is this client a sunset or a math problem? You don’t need to answer; in fact, it may be better if you leave answering to one side for a moment, and just sit with the image of the client and the question.

STRONG FOCUS ON WHAT SOMETHING MEANS ABOUT YOU WITH RESPECT TO OTHERS If some of your clients generate a sense of hopelessness, of helplessness, and perhaps of incompetence in you, do you find yourself reflecting on what that means about you as a therapist, perhaps even as a person? Do you find yourself wondering how you might stack up against your colleagues, or how other people in your life might regard you and your 139

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work? Do you find yourself drifting to thoughts of how your clients might describe you to others? Seriously entertain the idea for a moment that you’re a failure as a therapist and that even your best efforts will fade to mediocrity. Imagine, just for a moment, that no matter how hard you study, try, work, you’ll never be able to quite get in the room with your clients. Try this thought on for a moment: I’m a really weak therapist. Sometimes I can put on a reasonable show, but deep down, I’ll never be much of a therapist. What was your reaction to those words? Of course, I didn’t ask you to accept the fact of failure, just the thought, and even that for just a moment. At least some of our clients will precipitate a sense of failure in us, at least some time. How busy do you get managing that sense when it emerges?

EXPLANATION VS. DESCRIPTION When you speak of certain clients to colleagues, do you find yourself justifying or explaining why things are going poorly in therapy? Do you find yourself justifying your work to yourselves or others?

CATEGORIES VS. SPECIFICS Consider the ways that you speak and think about your most difficult clients and about yourself in relation to them. How much of your own speech is categorical and abstract as opposed to concrete and specific? How much of your speech (and thought) is “I can’t stand this” or “This is terrible?” Compare this to “When my client comes in and tells me about his failing marriage, I feel helpless. I remember my own parents’ divorce and how sad I felt the day my dad moved out. I see some of that sadness in my client’s eyes.”

THE FAMILIAR (AKA THE OLD AND STINKY) Winding up the mindiness list are the conversations you have with yourself and about yourself that seem just a little bit too familiar. Do you hear yourself saying things that you’ve heard before? Does the conversation you have with yourself about your competence as a therapist have the same ring as conversations you had with yourself about being a student, a partner in relationships, a friend? Check and see. If you sit inside thoughts of failure for a moment, what other things from your future and past are conjured in that stillness?

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Therapist Avoidance Strategies Next we’ll turn our attention to the many ways we therapists bind the anxieties stirred up in us by our clients. Don’t assume that the strategies described below are necessarily avoidant. You’ll need to sort that out for yourself. If we saw someone running down the street, we wouldn’t necessarily conclude that she was running away from something. She might be jogging. She might be running to see a good friend up the block who just got home. There are all sorts of reasons a person might run. What I list below are common ways that therapists run. Some of them look avoidant; some of them look positively virtuous. It’s your job to figure out which is which.

BEING PREPARED (REALLY PREPARED!) Being super prepared for every appointment with clients can be a very good way to feel safe. Of course, preparation isn’t the enemy. Preparation is fine. The difficulty arises when preparation becomes the functional and behavioral equivalent of worry. I’ve worked with therapists who make a fetish of preparation. When I sense some constriction around preparation, I often get settled in for a moment with the therapist and ask him to slow down and imagine coming into a session with absolutely no preparation at all—not one second. If I’ve read it right, he’ll suddenly stop breathing, freeze like a deer in the headlights, and begin uttering a stream of but, but, buts. I reassure him that I’m not asking him to actually go into a session unprepared. In fact, I’ve not asked him to do anything except imagine being unprepared. What fears rise up when he even considers being unprepared? What beasts loom around the edge of those fears? Failure? Incompetence? Worthlessness? Fears that he’ll get in that room and have no idea what to say?

NOT BEING PREPARED Although not being prepared is formally the opposite of the above, it can be functionally identical. Some clients cause such angst that we work hard not to think about them. Part of the way that can manifest is in a lack of preparation where preparation is appropriate. If you find yourself defending, with much energy or resolution, being prepared or not being prepared, it’s worth examining possible fusion and avoidance connected to preparation or a lack thereof. 141

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BEING BIG There’s an old saying that the best defense is a good offense. Looking like you’re in charge can sometimes ward off feelings of incompetence, confusion, or frustration. There are many strategies that can help you look and feel more in charge: sitting beneath a wall of framed diplomas, referring to authoritative studies and texts a lot during sessions, letting your conversation with clients stray to technical topics or analyses of analysis where you can really let loose with the vocabulary. Somehow our profession missed out on finding a reasonable excuse for wearing white coats and stethoscopes. But we have our ways.

BEING SMALL Although being big in one way or another is a common method of managing the difficulties faced as a therapist, being small can be equally protective. There are somewhat fewer strategies available, but you may find that these fit better with your usual methods of managing anxiety. You might look for moments when you avoid confrontation or when you don’t say things you think your client will find painful. Watch your voice for a flat and gentle, nonthreatening therapeutic tone. Take note if you always find yourself being kind and nurturing, never disagreeing, or never showing anger.

BEING AN EXPERT Doing a lot of psychoeducation, holding forth on the theory around treatment, and explaining the mechanics of a treatment model can be a great way to look and feel in charge. It puts you on ground that you certainly know with more depth than the client. On a personal note, this is my most likely mode of protection. I’m prone to going positively professorial in sessions and in supervision. The trouble is that I’m often correct in terms of content (but I’m just as often wrong in process), and I’ve had some practice at sounding like I know what I’m talking about. And I’ve been doing this a while, so I can go on and on and on. Sigh.

BEING CLEVER Getting to the heart of the matter and saying it out loud can help (well, help with feelings of incompetence). A good penetrating analytical mind can often make sense of what’s driving behavior. The trouble is, often enough, knowing plus a dollar leaves you short of enough money for 142

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a cup of coffee. Knowing that going outside won’t hurt a client and that doing so will ultimately lessen his fear—even if you do a very good job of communicating this fact—won’t necessarily alter a client’s motivation to leave the house. Being clever can take the form of insightful analyses, interpretations, and even treatment plans. But absent a connection with your client, your cleverest assessment or keenest insight might not do much to move her.

ALWAYS BRINGING A CLIPBOARD Holding a clipboard is one of my favorite ways to look like someone in charge. Go to any construction site. Look around. Who’s in charge? Look for the person with the clipboard, not the person with the shovel. Clipboards also have a physical presence that can serve as an actual barrier between you and the client. Be sure to take a lot of notes during the session. If you’re really in doubt, bring a lot of scripted questions. You will always know what to do next.

ASSIGNING LOTS OF HOMEWORK Another good way to be on top is to spend a fair bit of time assigning and reviewing homework. Remember school? Who gives the homework and who gets it? The teacher knows. The student doesn’t. The teacher evaluates. The student gets evaluated. If you need to stretch it out, you can also explain the rationale for homework in great detail.

BEING A GOOD LISTENER Many clients are willing to fill the session with stories. Sometimes you feel lost in this stream of stories. If you get quiet during a session, the whole hour can go by without your having uttered but a few sentences.

CHOOSING NOT TO INTERVENE Do you ever find yourself in session feeling like you should be doing something? You may not know precisely what you should do, but you have a sense that the session is going nowhere. Forced activity can sometimes manage this difficulty. Driven by your intolerance of not knowing what to do, you might get big in the ways described earlier. But you also might just sit and do nothing. You get busy in your head. You count the minutes until the end of the session and breathe a small sigh of relief when the client leaves. 143

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KEEPING IT LIGHT Some clients protect themselves from hard material by coming to session and taking about sports, politics, or other issues disconnected from their own growth and development. It’s very easy to join clients in these conversations. The hour will fly by. A variation on this is the client who brings in a steady stream of small problems. You can stay busy putting bandages on small scrapes as the client’s life bleeds away from larger, more central injuries. This is a particularly palatable way of staying small, since it has the form of doing good. And, by the way, the same applies to clients. In moving from one small problem to the next, they get to feel like they are doing good too.

STAYING BUSY, WORKING HARD Some client presentations are likely to precipitate busyness. Clients who bring in many, many problems often get us busy. Some versions of being big also involve being busy. Watch yourself in session and see if you tend to always put a lot of effort into your work with clients. If you do, pause a moment in session. Allow the busyness to settle around you. Examine your tolerance for periods of inaction. Hesitating a moment in these pauses can tell you something about how much “have to” is driving your busyness. Another thing you might look to in this area is ongoing interest in new therapies or a tendency to jump from model to model.

CHASING UNDERSTANDING Another common avoidance strategy is chasing understanding. The domination of insight-oriented psychology has a long, long reach. Psychoanalysis doesn’t have the influence it once had in mental health training, but its residue in the form of prizing insight and understanding remains. This is unlikely to change any time soon. It’s deep in the Western tradition and also in some interpretations of Eastern traditions. The core idea is that understanding the nature of a thing will allow us to act more effectively in response to it. I don’t believe you can overestimate the pull of understanding. Of course, understanding has delivered extraordinary gifts. ACT, however, isn’t an insight-driven model. It’s not so much that we don’t love insights. We do. They’re lovely. But we don’t believe that insight drives behavioral and emotional change. Rather, it’s the other way around. Check for yourself. Look at insights you’ve had. See if it isn’t 144

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the case that the insight followed some event or activity that changed your view. Some years back, I was at a meeting where the leader asked everyone in the room to stand up if they were between eighteen and twenty-two years of age. The group leader went on to say, “This is what your parents looked like when they made those decisions you’ve been mad about for the last few decades.” What did I see before me? I saw kids. I saw bright young faces, full of promise but largely unseasoned by the vicissitudes of decades. It was somewhat disheartening to find myself, a middle-aged man, blaming kids for, well, acting like kids. I made a decades-delayed phone call to my dad after that meeting. Did I have an insight? You bet. But the insight followed the experience of taking a different view. Insight is the exhaust, not the fuel. Experience is the fuel. Insight was also not the best thing that came from that experience. The best thing was a renewed relationship with my dad. The experience had several outcomes: insight, changes in relationships, and changes in my own view of myself as a son and as a father, among others. If I could only keep one, it would be regaining my dad. Chasing understanding is at such high strength that ACT has a variety of interventions aimed directly at pursuit of understanding as the royal road to well-being. Both clients and therapists are steeped in a culture that teaches us the virtues of understanding and insight. The trouble is that understanding is so unbelievably useful in so many domains of living. Understanding aerodynamics has allowed human beings to fly. Understanding math allows people to keep their checkbooks balanced. Understanding allowed my fine doctors to treat the cancer that threatened my life in 1998. Understanding is essential in developing a coherent and useful theoretical account of human behavior. It’s unquestionable that some human suffering arises from deficits in information and understanding. If someone with diabetes doesn’t understand which foods are and are not high in sugar, she may have trouble. If someone with an alcohol problem doesn’t understand that a drink—whether beer, wine, or whiskey—is still a drink, that person may have trouble. But very, very frequently, people already know as much as they need to in order to act in a way that’s consistent with their values. How many folks with diabetes know what they should and shouldn’t eat but continue to eat in ways that lead to blindness, loss of limbs, and death? How many people with drinking problems know that they need to stop drinking yet drink themselves out of jobs, families, and friends and straight into graves? 145

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Information is powerful medicine where it’s powerful, and weak medicine where it’s weak. Of course, our minds will always tell us that just a bit more understanding will finally do the trick. But what if pursuing understanding isn’t the best way to find it? Could this be? This is not to discount verbal understanding. However, there are some things that verbal understanding just can’t deliver. You could read every book in the world on swimming and still not know how to swim. To learn to swim, you have to get in the water. The ACT model is not antiunderstanding at all; it doesn’t, however, see lack of understanding as the most important cause of human suffering. Further, ACT identifies considerable suffering in harmful overextension of verbal understanding, especially into domains where it doesn’t help.

PROVIDING CONSOLATION One potential avoidance strategy is providing consolation to clients who are suffering. It’s quite natural to want to console someone in distress. But sometimes when clients are very troubled, we find ourselves compelled to do so. Sometimes we can’t tolerate how we feel when they feel how they feel. In chapter 8, we’ll use experiential exercises to explore the strength of that compulsion. Why would we care? Because sometimes consolation is just what the client needs, but sometimes consolation can be insulting. When I was being treated for cancer in 1998, I was very sick and very sad. I couldn’t look at my own children without wondering if they would have a father next Christmas or just a story about a father. My sadness was quite apparent. I had wonderful medical care. Most of the nurses and doctors who treated me provided a quiet presence as I sat sad in their offices. With a few, however, it was very clear that the consolation was really more about their feelings than mine. They couldn’t sit with me, and I didn’t want to sit with them. Their words had the form of consolation, but there was little consolation in them. We’re all susceptible to this, but consider how powerful it would be to be able to sit when sitting is called for and to console when that’s what is needed.

ALL OF THE ABOVE: MINDFULNESS AND AVOIDANCE None of the above phenomena are bad in and of themselves. Many are important and valuable. Being willing to chat a bit about last night’s ball 146

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game normalizes the conversation between a therapist and client. Being prepared for sessions may cause clients to see that you’ve thought about them and care about them. Understanding may lead to accurate and useful case conceptualization. The question we’re exploring here is the extent to which these behaviors are being organized by aversive control. To the extent that they are, we’ll expect to see those behaviors show the same properties as any other behaviors under aversive control. That is, we’ll expect the repertoires to be relatively narrow, relatively inflexible, and relatively insensitive to other sources of stimulus control. The difficulty with many of these behaviors is that they’re likely to be reinforced in several ways. I’ve described ways these patterns of activity may function to reduce aversive thoughts and emotions. A second source of reinforcement will often come from the clients themselves. For the client whose primary patterns of avoidance are passive, a therapist who is active and big may be quite welcome. A client who defends herself by keeping things trivial will likely welcome a nice chat. Clients who frantically lurch from one problem to the next may welcome a therapist who becomes activated with each new problem. If we’re in therapy and engaged in these various forms of behavior in order to manage our own difficult thoughts and emotions, or if we essentially join the client in his own avoidance, we’re less likely to be aware of small shifts in the client’s behavior. We’ll be less likely to be able to intervene in a way that’s sensitive to those shifts. Because of the inflexibility in our own behavior, we’ll likely have a much more difficult time noticing the ways our fusion and avoidance are interacting with the client’s fusion and avoidance.

READY FOR A CURVE? In the last two chapters, I’ve described signs you can look for in your clients that indicate a lack of contact with the present moment. And I’ve offered a rundown of similar things that you can be vigilant of in yourself. Learn to discriminate the difference between being in the room and not, and you’re well on your way to achieving mindfulness for two. But what about the bigger picture? The subtitle of this book promises An Acceptance and Commitment Therapy Approach to Mindfulness in Psychotherapy, and I find myself increasingly of the opinion that there are some aspects of mainstream psychotherapy’s current approach to diagnosis and case conceptualization that miss the mark of much of what I hold to be important in this work. Do you recall that I warned you to 147

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be on the lookout for a preference for categories over specifics in the therapy room, as this may a sign of mindiness? Well, what about a caseÂ�conceptualization and diagnostic paradigm that is exclusively based in categories? Syndromal case conceptualization, the dominant paradigm, tends to favor interventions based on classification according to behavior form over moment-by-moment, functionally focused analysis. While clinical specifics can increase function in present-moment processes, an alternative paradigm for case conceptualization can facilitate even greater sensitivity to these processes. Might it be that what’s good for the individual client and therapist is also good for the discipline as a whole? I’m betting that this is so. Accordingly, the next chapter sets out an approach to experiential case conceptualization that uses the hexaflex model as a foundation. And while it might superficially seem that this is a deviation from my purpose of promoting mindfulness for two, I think you’ll find, in the end, that it actually goes a long way toward furthering it.

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Chapter 7

Experiential Case Conceptualization

During the past several decades, empirical clinical psychology has focused on developing and validating treatments for various human difficulties. Since the achievement of a reasonable level of reliability in 1980 in the DSM–III, these efforts have been increasingly organized around categories described in successive iterations of the DSM. The American Psychological Association’s Division 12, the Society for Clinical Psychology, maintains a website listing empirically supported treatments. The list is described as “a list of psychotherapies for each disorder that are supported by evidence from carefully-controlled studies” (Society of Clinical Psychology, n.d.). Although the list isn’t wholly restricted to DSM diagnostic categories, it’s largely a list of specific treatments for specific DSM diagnoses. Likewise, the National Institute of Mental Health is largely organized around categories that overlap substantially with DSM categories or at least with the idea of distinct psychological syndromes such as anxiety disorders, mood disorders, alcoholism, and so forth. While the DSM has steadily improved in reliability, demonstrating the validity and utility of diagnostic categories has been more elusive. In 2000, O’Donohue and colleagues surveyed the authors of articles cited as evidence for the efficacy of treatments listed in Chambless and company’s 1993 report. One of the survey questions was “Is a DSM–IV diagnosis essential for making treatment decisions?” (O’Donohue, Buchanan, & Fisher, 2000). The majority of respondents, 61 percent, said they didn’t need a DSM diagnosis to provide treatment. When experts known for

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Â� producing evidence for the treatment of a diagnosis don’t find treatment utility in diagnoses, it’s suggestive of serious problems with the treatment utility of the diagnostic system.

THE TREATMENT UTILITY OF DIAGNOSTICS Consider the following recent assessment of the DSM effort: In the more than thirty years since the introduction of the Feigner criteria by Robins and Guze, which eventually led to DSM–III, the goal of validating these syndromes and discovering common etiologies has remained elusive. Despite many proposed candidates, not one laboratory marker has been found to be specific in identifying any of the DSMdefined syndromes. Epidemiological and clinical studies have shown extremely high rates of comorbidities among disorders, undermining the hypothesis that the syndromes represent distinct etiologies. Furthermore, epidemiological studies have shown a high degree of short-term diagnostic instability for many disorders. With regard to treatment, lack of specificity is the rule rather than the exception. â•…â•… Concerns have…been raised that researchers’ slavish adoption of DSM–IV definitions may have hindered research in the etiology of mental disorders. Few question the value of having a well-described, well-operationalized, and universally accepted diagnostic system to facilitate diagnostic comparisons across studies and to improve diagnostic reliability. However, reification of DSM–IV entities, to the point that they are considered to be equivalent to diseases, is more likely to obscure than to elucidate research findings. â•…â•… All these limitations in the current diagnostic paradigm suggest that research exclusively focused on refining the DSMdefined syndromes may never be successful in uncovering their underlying etiologies. For that to happen, an as yet unknown paradigm shift may need to occur… â•…â•… Many, if not most, conditions and symptoms represent a somewhat arbitrarily defined pathological excess of normal behaviors and cognitive processes. This problem has led to criticism that the system pathologizes ordinary experiences of the human condition. (Kupfer, First, & Regier, 2002, xviii-xix, 2) 150

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None of the concerns regarding syndromal classification in general and the DSM effort in particular drawn from this assessment, A Research Agenda for the DSM–V, are new. Some are, in fact, reminiscent of Thomas Szasz’s classic 1960 critique in his article “The Myth of Mental Illness.” There is something new in these critiques, however: they come from inside the establishment. While syndromal classification has always had vocal critics outside the DSM effort, David Kupfer and company represent one of the strongest internal critiques to date. A central problem with syndromal classification is that diagnosis is based entirely on the form of responses. From a behavioral perspective, this is likely to be problematic. One of the fundamental properties of the behavior of complex organisms is its remarkable flexibility of form. Even with a simple behavior like a lever press, a rat can be trained to press rapidly or slowly; spaced or continuously; with its left, right, or both paws; using only its head; or using only its hind legs. If we shape each pattern in the presence of a particular tone, we can cause the rat to behave differently by varying the order of the tones. The behaviors would all look different even though they’re functionally identical. Likewise, we can have behaviors that are functionally different but formally the same. If we train the rat to press the lever for water when tone A is playing and for food when tone B is playing, the presses would look the same but would mean different things. One is an “I want a drink” press, and the other is a “Can I get something to eat around here?” press. If we can see formal similarity and functional difference (or vice versa) in a pattern of behavior as simple as a lever press, does it make sense that we should be able to categorize enormously complex behavior strictly according to its form? We see enormous heterogeneity of response patterns even within the most reliably diagnosed DSM categories. There are many instances in which two individuals can have the same diagnosis and yet share only a single symptom in common. From a behavioral perspective, we’re generally more interested in function than in form. And speaking broadly about our clinical work, I think you’d agree we all know that merely describing the form of our clients’ behavior is not enough. In order to even begin to structure an effective intervention, we need to know more than a little something about the relation between the form of behavior and the function it serves for our clients. As Kupfer and his colleagues allude above, the DSM often treats altogether continuous clusters of phenomena as though they were separate and distinct, and it categorizes individuals into discrete diagnoses, any of which may be too broad or too limiting. Does anyone truly believe 151

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that there is an in-kind difference between the individual with five of nine symptoms and the person with only four? I mean truly believe it rather than subscribe to it in moments of legalistic or administrative rigidity. I find it very hard to imagine. Does this mean that biological psychiatry will never find any actual diseases, complete with sensitive and specific biological markers, fully elaborated pathohysiology, pathoanatomy, genetic predisposition, and response to treatment? No. Biological psychiatry will certainly find some. Over time, we’ll almost certainly find some disorders that rise up from mere syndromes to the level where they are properly identified as diseases. It seems entirely unlikely, though, that we’ll find a lot from the current crop of DSM disorders, given that we don’t currently have a single major DSM Axis I disorder for which we have even a single sensitive and specific biological marker. Not even one. Even if we find genuine causal neurological bases for psychiatric disorders, this doesn’t mean that the remedies will necessarily be biological interventions. Even where biological interventions are important, they’re unlikely to be exhaustive in their ability to remedy the sufferer’s problems. Traumatic brain injury has a clear physical cause, but much of its treatment requires behavioral intervention. Among psychiatric disorders, we know that a significant number of individuals with psychotic symptoms are unresponsive to our most effective antipsychotic medications. Even among those who are treated successfully, many continue to have residual symptoms. If syndromal diagnosis fails to meet our needs, though, it doesn’t mean for a moment that our needs are any less pressing or real. The raison d’être for clinical psychology abides: the ubiquity of psychological symptoms. To do the work we’ve all set out to do, we still need a system for recognizing, understanding, and ameliorating these difficulties. We need to find ways of shaping repertoires so sufferers can live vibrantly when difficulties are present, as well as when they’re absent. ACT is, at least in some sense, a response to this lack of resonance between the syndromal classification of psychopathology and our observation of people and their complex struggles in the world. Instead of looking for specific forms of certain syndromes, when we work from an ACT perspective, we look for our clients’ problems in living. We start with the notion that everyone has such problems. We also assume that the difficulties we see in clients, while perhaps more pronounced, are not different in kind from the sort of difficulties we all face. And finally, we postulate that, regardless of the underlying causes, psychological Â�suffering is altered by the ways in which we interact with it. 152

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While I’ve been accused of being a wild-eyed dreamer, I’m not enough of a dreamer to imagine that the DSM framers are going to give up on syndromal classification. Nor do I suspect that mainstream clinical psychology will give up on it any time soon. There is, however, an alternative strategy. It’s a strategy that starts small and slow. The alternative strategy is to build out multiple alternative systems that don’t require universal acceptance in order to make scientific progress. This approach is what we’re attempting to do within the ACT treatment development community. Part of the effort is the development of a set of midlevel theoretical terms, which can themselves be analyzed in very basic behavior analytic terms. Midlevel terms have the advantage of somewhat clearer applicability to clinical phenomena while remaining connected to more basic analyses. In this chapter, I’ll describe such an alternate strategy for classifying, assessing, and treating human psychological difficulties. This diagnostic model is built around the hexaflex, with which you by now have more than passing familiarity.

LINKING ASSESSMENT, DIAGNOSIS, AND TREATMENT WITHIN THE HEXAFLEX MODEL The hexaflex emerges from a contextualistic and holistic perspective. It treats difficulties that are continuous as continuous rather than discrete. All six dimensions of the hexaflex can be understood as continuously present from the clearest psychological problems to the problems of everyday life. The system that follows includes very strong connections among assessment, diagnosis, and treatment. Let us consider briefly the continuous nature of each of the six facets of the hexaflex and in that see how this linkage is retained.

Present-Moment Processes Present-moment processes appear quite dimensional in nature. We could ask at different points in the day, and from day to day, the extent to which this is true of ourselves. We would quite likely find that we vary on this dimension within and among days. If we examine the ways in which such a presentation can capture clinically relevant phenomena, classic signs of anxiety and depression will be apparent in worry 153

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and Â�rumination, as well as in deficits in concentration and attention. ADHD-type distractibility might be properly probed and coded on this dimension. Although the source of distractions might be different for a psychotic client, the distractibility would still be sensibly coded. Within the area of present-moment processes, we want to assess whether the individual is able to bring deliberate, flexible, yet focused attention to bear in the present moment. We can assess this quite simply in several ways, by observation: Does the person perseverate on the past or the future? Does the person make contact with her moment-bymoment experience without being directed to do so? If directed to do so, for example, by asking her to attend to some aspect of experience in the present moment such as bodily sensations, is she able to do so? Is she able to then shift attention when asked to do so? Is she easily distracted? Can the individual match the pacing of the therapist when instructed? This latter is a present-moment processes issue because the individual can’t match pace when she isn’t bringing attention to bear on the therapist. One useful way to probe present-moment processes is to examine a client’s ability to engage in what is called in ACT self-as-process—that is, can the client attend to and note aspects of his ongoing experience? This can be done in an extended exercise, such as the Observer Exercise from the original ACT book (Hayes et al., 1999). However, self-as-process can also be assessed in the context of assessment. For example, in the context of the discussion of valued domains or of difficulties, we can shift the conversation to questions about the client’s ongoing stream of experience, including thoughts, memories, and bodily sensations. The client’s ability to shift attention and to bring it to bear in turn on different aspects of experience constitutes a probe for present-moment processes. If extended, it constitutes a potential intervention that shapes present-moment processes. Note that there is a direct linkage between assessment and treatment. We assess and treat by coaching and shaping flexible, focused attention. The only real distinction between assessment and treatment is the duration of the probe. The purpose of the probe is to assess, probes will probably be shorter than treatment, which aims at remediation.

Acceptance Processes Likewise acceptance processes are wholly dimensional. We all, at least at times, have aversions and avoid in ways that don’t facilitate valued living. We don’t raise the price of our services because talking to 154

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our clients or our boss about our pay makes us feel uncomfortable. We don’t ask someone for a date because we’re anxious about rejection. We can assess avoided content and avoidant repertoires by asking our clients about important valued domains, what they see as major obstacles (possible avoided content), and how they manage those difficulties when they emerge (possible avoidant repertoires). Assess content that’s unacceptable. Remember, even things that seem pleasant may take on aversive qualities. Intimacy may be highly valued and terrifying. Content may take any form. Although experiential avoidance refers to aspects of one’s experience that are avoided, you should also list external events that the client avoids in assessing avoidance. Often external events are experienced as aversive in their own right. For example, situations involving interpersonal conflict may be avoided. Individuals doing so may find that these situations generate anxiety, fear, and memories of conflict that are also avoided. Remember that experiential avoidance may take many forms. What is the client rationalizing, tolerating, ignoring, or experiencing with resignation (which sometimes looks a bit like acceptance but without the vitality)? Where you see these you will find avoided content. Many of the items listed here will also be important as potential areas for defusion work. List external events, bodily states, emotions, thoughts, memories, urges, cravings, memories that are avoided. Finally, list the personal qualities clients see themselves as lacking (for example, courage or intelligence). We need to assess means of avoidance that need not appear to be avoidant. Avoidance is defined by the extent to which a response allows the client to avoid, escape, or attenuate the aversive content listed previously. Ask a client how she copes (for example, gets busy, distracts, or thinks positive thoughts). What clients do when such content emerges will provide a starting place for our list of avoidant repertoires. Remember, the form of avoidance doesn’t have to look pleasant. Depending on a client’s history, getting angry might help him to avoid feeling sad. Conversely, getting sad may help him to avoid feeling angry. Avoidance doesn’t even always have to look like avoidance, so things like putting up with, resignation, tolerating, fighting, and rationalizing might all be means of avoiding. Avoidance might also be apparent in the ways that a client relates to others. Some individuals have learned to use others’ responses to them to manage their own private experiences. For example, a client’s presentation may implicitly request some particular response on your part. Notice your own reaction to the client. Do you feel pulled to offer attention, permission, approval, pity, condemnation, abandonment, or some other 155

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social exchange? Your experience of being with that client is likely representative of what it is like for others to be with her. Psychological difficulties like anxiety and depression, for example, don’t exist in a vacuum. As we enter a conversation with a client about taking valued directions, he will present things like anxiety and depressed mood as obstacles. Or he will present external obstacles. However, if we inquire a bit further about external obstacles, we often find experiential barriers. A thankless husband might be an external obstacle, but we can go further and assess what experiential barriers there might be to either really saying yes to staying in the relationship or to saying no, leaving, and seeking another relationship. Examining experiential avoidance, both avoided content and avoidance repertoires, within a conversation about values reminds us of problems as situated in the context of those values. This makes it less likely that we’ll end up problem solving for problem solving’s sake. It keeps the work contextualized in values rather than contextualized in the usual flight from problems. Again, both treatment and ongoing assessment exist comfortably side by side. Level of willingness to linger in the present moment with difficult content tells us something about client avoidance (assessment) and is also simultaneously a sample of treatment for avoidance. The only particular distinction is that asking a person to linger a moment might be a brief way to collect a behavioral observation, whereas asking permission, coaching, encouraging, and shaping willingness in a more drawnout way would constitute treatment.

Defusion Processes When we assess defusion, we’re interested in life-organizing stories and in how tightly these stories organize life. We’re less interested in the veracity of the stories, although veracity will be compelling for the therapist. We’re so used to playing the true/not-true game. If a story organizes life in very constrained ways, asking about the truth of the story is akin to asking, when we see a rat conditioned to cringe when a tone is sounded, whether the tone is “true.” Sometimes “de-truthifying” can be a good intervention. “The bathroom is down the hall to the left, not the right” might reorganize your bathroom-seeking behavior, but most of our clinical problems are far less likely to succumb to a simple correcting of information. I know this is repetitious from previous chapters, but the slope is so slippery, I want to offer extra warnings. 156

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We’re seeking to assess the level at which stories organize life in ways that inhibit valued living—typically through loss of contact with other important aspect of the current life situation. What we’re interested in examining is the breadth and integration of fusion. To understand what is assessed, it can be useful to have a sense of the continuum of fusion. The prototype case for infinite breadth and integration would be a case of a very strong delusion. Just for reference, a delusion is the holding of some belief in the face of strong contrary evidence. I once treated a fellow who claimed to have been in Vietnam and to have gone behind enemy lines to assassinate members of the North Vietnamese general staff and politicians supportive of the North Vietnamese Army. A look in his records revealed that he had been in the military for a very, very short time in 1970. He’d had a psychotic episode in basic training and had mustered out of the military with medical discharge. When asked about this, he replied, “Do you suppose they would put ‘assassin’ in my military records?” When I mentioned that his mother corroborated the story, he responded, “Yes, the government got to her too.” Of course, such delusions can be wholly impenetrable. Any countervailing evidence is simply rolled into the delusion. In fact, sometimes strong evidence to the contrary can have a strengthening effect. Suppose we could extract every Vietnam-era document from the Pentagon and Department of Defense and there was no evidence for this client as assassin. I suspect the client would say, “See how deep the conspiracy runs?”

EXERCISE: But What of the Continuum? Take a moment and consider the deepest and most long-standing fear you have about yourself. If you want to see how susceptible you are to such fears, very slowly read each of the following statements aloud and allow the words to sink in, let yourself know the truth of it (if any) inside your skin, inside your own life. Just notice what comes up:

• I’m just not very lovable. Most people don’t see it, but if they really get to know me, eventually they find out.

• I’m not a nice person. A lot of people don’t know how petty

I can be. I talk about people behind their backs. Sometimes I see myself doing it and I wonder, why, why am I doing this? But there I am, being me.

• I’m a big mouth. I always have to have the last word. You just can’t know how many relationships this has killed. Mostly I

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don’t notice until it’s too late. Even when I do, sometimes I just watch myself walk off the cliff.

• I’m a doormat. I let everyone walk all over me. I sit in meet-

ings and other places and I have something to say, but I just sit there like an idiot and take it. I don’t know what’s wrong with me.

• I’m stupid. Most people think I’m one of those who always seems to get it, but I’m really always one step behind. So I pretend to get it, and then work really hard later to figure it out.

• I’m guilty. Most people don’t know the things I’ve done, and

how much I don’t deserve the things that I have. The people who do know will never be able to look past them, no matter what.

• I’m spineless. Most people probably can’t tell, but I walk around scared all the time. I’ve missed out, and the people I love have missed out so many times all because of my fear.

• I’m selfish. I seem to be really caring, but I never do any-

thing without expecting some kind of return. When I don’t get it, I’m mad, but I never say that out loud.

If any of those had some resonance with you or called up other thoughts that have the same flavor, notice how long those thoughts have been hanging around. Perhaps you think that you’re not really very smart. You got through graduate school and everything, but you know how often you were clueless in class (and kept it hidden). You know that you had to work twice as hard to understand half as much. You know how clear it was, sitting there among the other students, that their grasp exceeded your own. You know that you’ve come up with good strategies to keep this fact hidden—sometimes even from yourself. Just settle into that (or another scenario that’s a better fit), and then suppose that we asked someone who knows and loves you about your not being very bright. What would they say? Might they say, “What about getting As all through grad school?” “But I got a B in assessment. And, really everyone got As.” “What about that student paper competition you won?” “That was a fluke. I know other papers were better than mine.” 158

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“What about your job as a college professor?” “There are plenty of stupid college professors.” Can you see how readily you could deflect contrary evidence? Is there any event that has happened in your life that this loving friend might recount for which you couldn’t offer counterevidence? I assume that we all have some version of such resilient self-deprecation. We have often tried to argue these thoughts away, wish them away, and work them away—and here we are. Notice your own urge toward struggle or resignation. See if you can find any sense of life in either of those. And further, when we reflect on the resistance these beliefs about ourselves have to evidence, let’s recall the definition of a delusion: beliefs held in the face of strong contrary evidence. Within the area of fusion, dimension we assess fused thoughts, beliefs, and emotions; evaluations; stories about how the world is, what happened (past fusion), and what the future will be like (future fusion); why clients believe they have the problems they have (past fusion); and beliefs about what would have to happen in order for them to move ahead in life and whether that’s viewed as possible. Include stories about people in the client’s life, especially when “how they are” is a strong theme. Also include stories about past, future, and current situations that have the feel of inflexibility. Work to get a felt sense of the interiority of these stories (bring present-moment focus to them). Stay out of conversations about the veracity of possibility/Â�impossibility, truth/falsity, or justice/injustice of the stories, except to get a felt sense of the client’s experience of possibility/impossibility, truth/falsity, or justice/ injustice—stay mindful, these will hook you! In working through the hexaflex assessment process, in your probes for values, capacity to make contact with the present moment, and capacity for acceptance, you will see examples of fusion emerge. The client’s inability to engage in such probes without lapsing into repetitive stories and reasons, rumination, and worry are representative of fused content. Intervention will differ from these probes in that in treating we’ll persistently draw clients back to the present moment, back to their values, back to the possibility of accepting difficult things in the service of their values.

Self-as-Context Processes There are several difficulties we’ll see in assessing self processes. The most common difficulty will be fusion with self-as-content. Fusion with 159

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self-as-content is a subset of the larger process of fusion. Some fusion is about the world, what has been, and what will be. But an important subset of fusion is self-relevant fusion. Many of the examples provided in the previous section are fusion with self-as-content. The most common versions we might see clinically would be among clients who are wholly identified with their symptoms and, at times, with their diagnoses. I’m anxious, I’m bipolar, and so on. In very chronic cases, the syndrome almost entirely eclipses the person. You may find it difficult to have any conversation with the person that doesn’t contain substantial reference to the signs and symptoms he’s experiencing. Nonclinical examples of fusion with self-as-content include things like fusion with certain roles. The stay-at-home mom might experience something of an identity crisis when her children grow up and move away. The person with a high-powered career might experience a similar dilemma when her career comes to an end. In these instances, there is a sense of “if not this, who am I?” when the role drops away or changes substantially. Or the change in role precipitates a sense of bewilderment without any strong awareness of the source of the difficulty. Such attachments to stories we write about ourselves are something we all have in some measure. Many of our attachments to self-as-content likely run under the radar, but a sense of our attachments is sometimes precipitated by crises of one sort or another. Death, near death, serious illness, job loss, and divorce for example, can, bring attachment to role into high relief. The presence of self-as-context—including thought, emotion, role, and body—can be both assessed and treated by moving among different domains and examining the flexibility and context sensitivity with which the client navigates those transitions. For example, if one asks questions across the domains of the Valued Living Questionnaire (presented in appendix B), does the client perseverate when transitions are prompted? Within and among domains, do we see stereotypies in speech patterning and content emerge? If we ask the client to imagine a different outcome for himself, given exactly the same history, can he do that with reasonable readiness and flexibility, or does he lapse back into his story about himself? Another version of fusion with self-as-content can be seen among institutionalized and some seriously mentally ill and developmentally disabled clients. Among such individuals, we sometimes see a sense of self that is extremely impoverished. Among institutionalized individuals, questions to which the answer begins with the word “I” are often quite

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impoverished. Such individuals may be asked few questions that cause them to be self-reflective, with the possible exception of questions about signs, symptoms, and medications. Here there is a narrowness that is driven by the poverty of the predominant questioning environment. Even when clients aren’t institutionalized, our clinical conversations frequently become fixed on client problems. The persistence of these narrow conversations carries the risk of actually fostering client fusion with a narrow band of content. A conversation that moves flexibly among difficulties and valued domains, among what is sweet and what is sad, can provide an assessment of client fusion with self-as-content. If done in an extended way, it can provide a treatment that promotes flexible interaction with self-as-content and can lay the groundwork for questions such as “And who is it here that notices all that is sweet and sad?” Likewise, doing self-as-context process work in the form of a brief version of the Observer Exercise (Hayes et al., 1999) with a client can both probe capacity to make contact with a sense of self that transcends the contents of consciousness and provide a treatment that fosters such an awareness if done in an extended form and repeated over time. All of these are means by which we can assess our central interest in the client’s capacity to interact with self in a flexible way and to make contact with an “I” that is not the content observed.

Values Processes There are a variety of difficulties we’ll want to assess in the area of values. Some clients will present with a very confused sense of what they value. As we assess using the Valued Living Questionnaire domains, such confusion will be apparent. Other clients will present with an assertion that they don’t care about anything. Ironically, they sometimes care deeply about not caring. It is ironic, of course, because valuing not valuing is valuing. Some clients will come to us in a state where some or all valued domains haven’t been exercised in a very long time. Among these individuals, a sense of valued direction may be weak or absent. Another variation of client difficulties in this area will be clients who enter treatment with different versions of strongly held values. In one version, the value is asserted as strong and consistently lived. This client may confess to an array of difficulties but also assert that she’s an excellent parent. What we want to assess is not so much her goodness as 161

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a parent as the inflexibility with which the value is held. Note your own experience as you listen to these assertions. Does it feel as if the person is trying to justify or defend herself? Does it feel as if she’s trying to convince you? Does it appear that she’s clinging to the value like a life preserver, or holding it gently like something treasured? Another variation on this theme is the client who has some strong, clear value and also has a strong sense of not living consistently with the value. Look for the presence of either struggle or resignation with respect to the value. Sometimes what we’re seeing is a sort of defensive valuing. This isn’t to say that there isn’t also a deeply felt value there to be lived. However, sometimes we cling to a value out of fear. Holding values in fear, like any other behavior under aversive control, is likely to be less flexible and less sensitive to subtle shifts in context. Over time, most values require flexibility to be well lived. Assessing sources of inflexibility for potential treatment will not strip away the value, only the driven quality of its pursuit. A final variation worth mentioning is the client who has a very small set of valued domains where there is much thought or activity. For example, the highly stressed, low-paid, single parent who has narrowed his values down to work and parenting—perhaps regretfully having let many other areas go. Narrowing of valuing is not necessarily problematic; however, when it’s done under duress, it’s worth investigating. Ask the client to describe domains of valued living as dynamic, ongoing patterns. Generate short narratives in relevant valued domains. Linger inside the questions about valued domains before allowing any answers. Stay in the questions. Again, this is not mere information Â�gathering. Mindful appreciation is key. Many of the difficulties described above will arise from values fusion either directly or indirectly. The markers for values fusion are the same as the markers for any other form of fusion. Look for a certain narrowing of repertoire. Look for stereotypies in patterning and content of speech as you discuss certain values. Probes when values are absent or confused might include questions like “I get that you just don’t feel like there’s anything in any of these areas for you, but if a strong sense of value were to somehow rise up in one of these domains, which would mean the most to you?” You might ask, “Was there a time when you did have a strong sense of valuing in this area? Can you tell me about that? Was there a time in your life when you thought this would be a lifelong value? When was that? When did that change? What happened? Do you have any thoughts or memories about that as we speak of it here and now?” As we do the values assessment, we need to be mindful that it is not mere information that we seek. We want appreciation more than 162

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we want information. Probes in the area of values should seek specific events that are prototypical in carrying the grit and grain of the client’s experienced value. It’s hard to really get the phenomenology of a client’s value when speaking in terms of categories. Assess for values where a sense of constraint, “impossibility,” “have to,” or values as a burden emerges. If parenting is a value, ask the client to close her eyes for a moment and actually see a parenting moment from her history that exemplifies the value. If she can’t recall one, ask her to create one that would be small, simple, and sweet for her. Help her to become mindful of that moment and ask her to help you to see and feel what she sees and feels detail by detail. Especially early on, clients may struggle to do so; don’t push beyond their willingness. Thank them for even showing you how hard it is. The client’s difficulty in this is precisely what we want to assess. In doing values assessment, we will see examples of fusion and avoidance connected to values. These will in turn become targets for treatment. As with all hexaflex assessments, extended versions of these assessments will comprise important aspects of treatment. The high-water mark in the area of values is the capacity for flexible, defused valuing. Can the client become present to what he values without having to act? To the extent that is so, he is free to construct and act on valued patterns of behavior with sensitivity, flexibility, and a genuine sense that those acts are freely chosen.

Commitment Processes Work in this area begins when you assess committed action and the meaning of commitment for clients. In a world where the client could make and keep commitments, what commitments would she make and keep? What is a major commitment he would like to make and keep? What small but meaningful commitment would she like to make and keep? Very present-moment focused assessment will be helpful here. The major problems in the area of commitment processes include inaction, impulsivity, and avoidant persistence. As with values processes, fusion is a central driver of commitment problems. In fact, it’s almost impossible to assess values problems without seeing indicators of Â�commitment problems. Commitment processes are quite tightly linked to values processes. This is true to the extent that much of the fusion we see in assessing values is actually commitment fusion. As soon as we speak a value out loud, the action implications of the value rise up 163

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Â� psychologically. This arising will include both what has been done and what must be done. A history of difficulty and failure within a valued domain is very likely to generate fusion and, with it, avoidance. Assess client stories about commitment—especially failures, inevitabilities, or any story that contains a strong sense of limitation or constraint. You’ll find these if you mindfully examine commitments across valued domains. Assessment in this area centers primarily around inflexible stories about commitments, both those made and those missed. Within these conversations, we’ll find indicators of commitment fusion—stereotypy, inflexibility, and repetition, as well as other markers of fusion and avoidance. We ask clients about commitments they’d like to make and what they see as obstacles. We ask about what they believe they can do. We ask about what they wish they could commit to. The target in the area of committed action is the capacity for defused, accepting committed action. As with values, we seek for our clients the ability to make Â�commitments that are chosen rather than driven.

EXERCISE: Commitment Scaling This is a good way to both assess and treat commitment processes. Start by helping the client get in touch, as much as possible, with some valued domain within which she would like to grow. Tell her that you’re going to ask her about commitments in some area. Make it clear that she need not carry out any of the commitments, just generate commitments that are consistent with the direction she would like to grow. Take a mindful moment and ask the client first to think of a major commitment that she could make in that area. Next, ask her to think of the tiniest possible commitment—one that might not even be noticed by someone else but which would be meaningful to her. After that, ask the client to think of an array of commitments that might lie between those two. Some clients will be completely unable to generate an array of commitments. Some will become very fused with some major commitment or fused with their inability to carry out a commitment. These are all interesting variations on fusion around commitment, especially in light of the fact that we’ve explicitly told clients that they need not actually make, let alone keep, the commitment. The probe is enough for assessment. An extended version of this exercise in treatment can serve to build flexibility with respect to commitments. 164

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GENERAL THOUGHTS ON THE SYSTEM These processes can themselves be analyzed in terms of basic behavioral principles. They’re at a level of abstraction that’s high enough to capture a very broad array of clinical phenomenon and yet low enough to be directly and readily linked to a wide variety of clinical difficulties. Our goal is the production of a fully dimensional model that can capture any and all difficulties seen in human psychological suffering, including both clinical and nonclinical examples. The system isn’t proposed as excluding other sources of difficulties. For example, a head trauma might have important psychological sequelae. While the head injury itself isn’t a psychological concern, the manner in which the individual contends with that injury is. The purposes of the system are these: 1. The system should aspire to provide a process account of any and all forms of human psychological difficulty. 2. The processes should be at a level of abstraction such that they have maximum scope (as described in 1) while being at a sufficiently low level of abstraction as to be useful to practicing clinicians and researchers alike. 3. The processes should themselves be analyzable in terms of more basic behavioral processes. 4. The account should produce a stream of integrated basic and applied research, as well as a stream of research bridging basic and applied domains. 5. The account should integrate assessment, diagnosis, and treatment such that a relatively close connection is made among the three. 6. The account should, with training, cause the researcher or treatment provider to see certain functional relations among the six facets of the model as they occur in an individual case or class of cases. The full explication of an alternate diagnostic and its rationale is beyond the scope of this book. However, what I will provide is a template for doing assessment using the hexaflex as a guiding structure. The value of such an assessment is that it creates a close link among assessment, diagnosis, and treatment. The hexaflex diagnostic is built in the spirit 165

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of behavioral assessment. The earliest behavioral assessments sought to sample the behavior of interest quite directly. If a person had a snake phobia, we might stand him at one end of a room with a snake in a vivarium at the other end of the room. We would ask him to walk toward the snake as far as he was able. We would then measure the distance between him and the snake. There’s elegance to behavioral assessment in the direct linkage among assessment, diagnosis, and treatment. Assessment involves proximity of approach; diagnosis is made if the client cannot approach. Treatment involves approach. Successful treatment is assessed by change in the ability to approach. Similarly, we will assess each area of the hexaflex as directly as possible and will attempt to make the same linkage between assessment and treatment. In fact, the assessment itself forms the beginnings of treatment and informs the future direction of treatment. Some claim that doing psychotherapy is an art. It seems clear, when I look at my own work, that some of it has been quite artful and some painfully artless. If we want a science of this and other therapies, however, case conceptualization is essential. We see a continuous stream of behavior in a client and a thousand potential contextual factors that might be influencing that stream of behavior. How are we to understand a behavioral episode? This is inherently a conceptual matter. We need to be able to conceptualize troubling or fruitful episodes and recognize the contextual determinants of that stream of behavior in order to know what intervention might be applied to free the client to move forward in her life. However, there’s a problem with case conceptualization. Case conceptualization quickly becomes too conceptual. I’m fond of telling students that categories are lies. Categories at once mean too much and too little. Once we get things categorized, the categorization quickly stands in for the world. When we say that a client has a “borderline” diagnosis, such a label organizes lots of behavior on the part of therapists, and often in ways that aren’t very helpful to the client. In addition, it’s not really terribly clear what that label means, since there’s tremendous heterogeneity of signs and symptoms possible even when the label is accurately applied. In addition, the label contains none of the heroism, beauty, intelligence, and strength that are often also present with such clients. ACT case conceptualizations share the danger of losing track of the actual human being treated. I’m asking you to cultivate a mindful, open, accepting approach to clients, and I’ll ask that you carry that gentle posture forward in the development of case conceptualizations. We therapists can become quite fused with our conceptualizations to the point 166

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where our view of the client and his behavior is so harnessed to the conceptualization that we lose close contact with the client. Understanding this danger, some therapists resist any sort of conceptualization. Such a solution puts therapy entirely into the realm of art. It’s not a solution that’s conducive to scientific development. I care about science and am alive today in a dozen ways as the direct result of the application of science. I’m sympathetic to the rejection of case conceptualization and think I appreciate the downside. But if our science of human freedom is to move forward, we need to learn to do a gentle dance with conceptualization. In many respects, this is consistent with ACT as a treatment model. We don’t teach our clients that thoughts are the enemy. We teach them to hold their thoughts lightly. Thoughts about clients aren’t different in kind. Thus, as therapists, we seek ways to think about our clients, to use those conceptualizations when they’re useful, and to gently let them go when they aren’t.

EXPERIENTIAL CASE CONCEPTUALIZATION In what follows, I’ll describe the Hexaflex Functional Dimensional Experiential Interview (HFDEI). This is an unusual interview. First, it doesn’t bow to syndromal classification. The user of the interview need not discard syndromal classification. Many circumstances require them. Although the diagnoses in the HFDEI are not DSM syndromes, many of the signs and symptoms required for DSM diagnoses will be elicited in the context of this interview. Second, the interview is organized around a dimensional understanding of psychological difficulties. Third, and probably most unusual, the interview contains significant experiential components. The interview for the hexaflex is not a mere series of questions; rather, it involves a set of questions embedded in a series of experiential exercises. The exercises and questions will provide you with directly observable samples of client behavior that will allow for rating those behavior samples in terms of the six facets of the hexaflex. The entire interview is embedded in a series of questions about valued domains of living. ACT is not a treatment aimed at the elimination of symptoms; it’s a treatment aimed at the enhancement and development of valued living. Because there’s an intimacy between values and vulnerabilities, an examination of values is a likely entry point to seeing the relationship between difficulties with behavior change processes on the one hand and mindfulness processes on the other. In addition, such an interview helps you and 167

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your client remain closely connected to the ACT model. Work with client struggles is always directed and dignified by valued living. Likewise, progress in ACT is ultimately to be found in increases in valued living. This interview is in its earliest developmental stages. Because of this, I recommend that you use it in conjunction with all usual and valuable assessments that constitute good ethical treatment. The interview does not, for example, contain a formal mental status examination, although in my experience it’s quite simple to assess all aspects of mental status within the interview. I currently recommend using the interview in conjunction with a good symptom checklist. The interview can be quite compelling, and I don’t want you to neglect screening questions for things such as suicidality, homicidality, and substance abuse, for example. In addition, many will use the DSM in treatment environments where syndromal classification is a requirement. I anticipate that many, if not all, of the data needed for a DSM diagnosis will emerge within the interview process. Any additional gathering of information should be guided by the practitioner’s ethical responsibility to provide sound treatment.

Hexaflex Functional Dimensional Experiential Interview (HFDEI) The following interview consists of six components. Taken together, they comprise a set of interventions and assessments that could be used as the initiation of treatment. Several of the components are also usable in a stand-alone form. I’ll describe them in the sequence intended for the full interview and will also suggest ways interview components might be used alone. The interview consists of the following six steps: 1. The therapist introduces the HFDEI. 2. The client completes the Valued Living Questionnaire. 3. The therapist does the Sitting Inside Significant Questions Exercise with the client. 4. The client completes Experiential Writing Exercise. 5. The therapist and client complete the experiential interview using hexaflex rating scales and worksheets. 6. The therapist completes a working hexaflex case formulation.

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INTRODUCING THE HFDEI Most diagnostic interviews involve the systematic enumeration of various signs and symptoms that would allow a diagnosis. In order to orient the client to the hexaflex diagnostic, you simply introduce the diagnostic by saying something like the following: I’m deeply concerned for the ways that you’ve suffered. Many treatments examine the nature of that suffering quite directly. My approach will differ in that I’m most interested in the ways that your suffering has obstructed the sort of living you’d like to do. Perhaps it’s stopped you completely in some areas. It may also be that you’ve continued to do well in these areas, but your suffering has taken some of the vitality and joy out of areas of living that are important to you. We’ll start by taking a very close look at areas of living that many people value, and we’ll look for the ways that you’ve felt restricted or perhaps just ways that you’d like to grow and develop. In the midst of this, we’ll find your major difficulties, but we’ll see them in light of what you value. Some of the conversation we’ll have will involve me asking you to close your eyes, relax, listen, and perhaps visualize some domains of living that are of differing importance to you. We’ll take our time in order to cultivate an appreciation of what you’ve suffered and how that fits in your life.

USING THE VALUED LIVING QUESTIONNAIRE-2 This interview uses a slightly extended version of the Valued Living Questionnaire (VLQ-2), which appears below. This version contains the original VLQ items (see appendix B) in a slightly altered form, along with additional values-oriented questions. It asks the client to look at life domains and to answer a variety of questions. Clients are asked to assign a numerical rating from 1 to 10 stating the extent to which they (1) think it possible that something meaningful could happen in their life the domain, (2) find the domain important to their life at this time, (3) find the domain important to their life as a whole, (4) have acted in the service of a value within the domain in the past week, (5) are satisfied with their level of action in the domain in the past week, and (6) are concerned they won’t make as much progress in the domain as they would like.

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On a separate page of the VLQ-2 (which appears only in the PDF version on the accompanying disc), clients are asked if they had to choose only five areas that they could work on, which would they choose; if they could only choose three, which would they choose; and if they could choose only one, which would they choose. They are asked to consider these questions both at this time in their lives and in their lives as a whole. The version of the VLQ-2 below is for your ease of reference. If you plan to use the VLQ-2 with clients, please use the copies of the PDF version on the accompanying disc.

Valued Living Questionnaire Below are areas of life that are valued by some people. We are concerned with your quality of life in each of these areas. You’ll rate several aspects in regard to each area. Ask yourself the following questions when you make ratings in each area. Not everyone will value all of these areas, or value all areas the same. Rate each area according to your own personal view of each area. Possibility: How possible is it that something very meaningful could happen in this area of your life? Rate how possible you think it is on a scale of 1 to 10. 1 means that it isn’t at all possible at all and 10 means that it is very possible. Current importance: How important is this area at this time in your life? Rate the importance on a scale of 1 to 10. 1 means the area isn’t at all important and 10 means that the area is very important. Overall importance: How important is this area in your life as a whole? Rate the importance on a scale of 1 to 10. 1 means that the area isn’t at all important and 10 means that the area is very important. Action: How much have you acted in the service of this area during the past week? Rate your level of action on a scale of 1 to 10. 1 means you haven’t been active at all with this value and 10 means you’ve been very active with this value. Satisfied with level of action: How satisfied are you with your level of action in this area during the past week? Rate your satisfaction with your level of action on a scale of 1 to 10. 1 means you aren’t at all satisfied and 10 means you’re completely satisfied with your level of action in this area. Concern: How concerned are you that this area won’t progress as you want? Rate your level of concern on a scale of 1 to 10. 1 means that you aren’t at all concerned and 10 means that you’re very concerned. 170

Possibility

Current Overall Importance Importance

Action

Satisfied with Action

Concern

1. Family (other than marriage or parenting) 2. Marriage, Couples, or Intimate relations 3. Parenting 4. Friends and Social Life 5. Work 6. Education and Training

8. Spirituality 9. Community Life 10. Physical Self-Care (diet, exercise, and sleep) 11. The Environment (caring for the planet)

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12. Aesthetics (art, literature. music, beauty)

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7. Recreation and Fun

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SITTING INSIDE SIGNIFICANT QUESTIONS EXERCISE Introduce and present justification for the exercise Sitting Inside Significant Questions, which is a values-focused centering exercise, saying something like the following: In this first part, we’re working to get a sense of how different life domains are more or less important to you. We’ve both come in here kind of busy, with the activities from the weeks, days, hours, and minutes before pushing us along, and I want to make sure that we treat these topics with the respect and attention that they deserve. So I’d like to take just a minute briefly for us to settle here in the room and to call to mind these different domains. First, I’ll help you to settle in, and then I’ll ask you a series of questions. When I begin to ask questions, you don’t need to come up with answers. Instead I’ll ask you to just linger with the questions. I’ll pause with you, and together we’ll just see how each group of questions moves us. Say the following slowly, using a soft, deliberate voice. Pause frequently and allow yourself and the client to settle into the questions. As you move through each set of questions, note any shifts in physical indicators of psychological flexibility. Watch especially when you transition from one domain of valued living to the next. Watch for changes in breath, in nervous movements, and other transitions. The HFDEI worksheets contain places to rate and make qualitative notes about any physical changes you notice. Each of the domains of valued living will be explored in detail in the interview, so, though you might be drawn to inquire around changes you’ll see, please use this first exercise with a relatively passive observation and appreciation. First, let your eyes close and see if you can just breathe in the experience of being here in this room right now. See if you can allow your eyes to gently close. Sit up straight in your chair with your head balanced at the top of your spine, allowing your shoulders to drop and the muscles in your face to relax. I want you to just take a moment, and I want you to just let your attention come gently to rest right now on the inflow and outflow of breath. And if you find yourself thinking forward to what we’re doing, gently let go of that and notice again that in the midst of all that mental activity, your breath continues. No matter how busy you get, it’s there, flowing like a river. It requires nothing of you. Just let yourself linger for a moment inside that steady stream of inflow and outflow of breath. Each time you find yourself drifting away in thought, into the future or past, just let that steady inflow and outflow draw your attention gently back. Allow yourself to just notice all of the tiny 172

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sensations—in your lips, your mouth, the gentle rise and fall of your own breath—each time you drift, gently returning back to your own breath. And if you find yourself irritated, wanting to move along, just notice that—that push—and imagine that you just gently release that and come back to this very next breath…and this breath. You should ask the client to keep eyes closed and transition directly into the following: I’m going to ask a series of questions about areas of life that some people value. Some of these areas may be very important to you. Others may not. Some areas you may think, no way! Others will seem just right. It’s not necessary that you value all areas. I just want you to listen to the questions and allow yourself to sit for a moment with each set of questions. Even if the area isn’t one that’s important to you, just let yourself be curious about the question. Notice any thoughts, feelings, sensations, or memories that come up for you and then gently release them. These are important areas of living, and we don’t always pause and give ourselves time to appreciate them. I don’t want you to necessarily answer these questions. Just imagine that these questions flow over you like water. Just let the questions soak in. If you find yourself drawing any conclusions, just gently let go of those conclusions and return to the question. And as you notice your reactions, let go of the urge to understand them, to judge them, to grip onto them, or to push them away. When you notice your reactions, just breathe that experience in, and on the next exhale, slowly set it aside and see what shows up next.

Family Let’s look at the area of family generally—outside of marriage and parenting. Ask yourself, if something were to happen in your life in the area of family, what would that mean to you? What does it mean for you to be a son/ daughter, a brother/sister? What does family mean to you? Listen to these words and just let yourself settle into each of them, noticing whatever shows up. [Allow pauses between each word.] Brother, sister, grandmother, grandfather, granddaughter, grandson, cousin, aunt, uncle, niece, nephew, family. Once again, just allow yourself to settle into those questions. Let yourself settle into the meaning of these things for you and allow your awareness to stretch out into the questions. And gently breathe. Just settle and allow your attention to come gently to rest on your own breath. [Pause briefly.] 173

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Marriage, Couples, or Intimate Relations And now we’ll begin with intimate relations. Please allow yourself to sit within these questions. Ask yourself, if something were to happen in your life in the area of intimacy, what would that mean to you? What does it mean for you to be a lover, a partner, a husband/wife? Just allow yourself to settle into those questions, allowing your awareness to stretch out into the questions. And gently breathe. Just settle and allow your attention to come gently to rest on your own breath. [Pause briefly.]

Parenting Ask yourself, if something were to happen in your life in the area of parenting, [if the client is not currently a parent, say, “even if you aren’t a parent now, let yourself stretch out in imagination,”] what would that mean to you? What does [or would] it mean for you to be a parent? Once again, just allow yourself to settle into those questions, allowing your awareness to stretch out into the questions. And gently breathe. Just settle and allow your attention to come gently to rest on your own breath. [Pause briefly.]

Friends and Social Life Next, let’s look at the area of friendship. Ask yourself, if something were to happen in your life in the area of friendship, what would that mean to you? What does it mean for you to be a friend? To have friends? If your friendships grew and changed, what shape might they take? Would old friendships be renewed, would new friendships grow? Once again, just allow yourself to settle into those questions. Once again, let yourself settle into the meaning of these things for you and allow your awareness to stretch out into the questions. And gently breathe. Just settle and allow your attention to come gently to rest on your own breath. [Pause briefly.]

Work Next, let’s look at the area of work. Ask yourself, if something were to happen in your life in the area of work, what would that mean to you? Would 174

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it perhaps mean finding new life in the work you do? Or perhaps is there is other work you’ve wanted but held back from moving toward? Whatever it means, just allow yourself to settle into this question. If something new, something with life could emerge in work for you, what would that mean to you? Once again, just allow yourself to settle into those questions. Once again, let yourself settle into the meaning of these things for you and allow your awareness to stretch out into the questions. And gently breathe. Just settle and allow your attention to come gently to rest on your own breath. [Pause briefly.]

Education and Training Next, let’s look at the area of education. Ask yourself, if something were to happen in your life in the area of education, of learning something new, or learning more in some area that you care about, what would that mean to you? Would it perhaps mean finding new life in learning? Is there perhaps education you’ve wanted but held back from moving toward? Whatever it means, just allow yourself to settle into the meaning of these things for you and allow your awareness to stretch out into the questions. And gently breathe. Just settle and allow your attention to come gently to rest on your own breath. [Pause briefly.]

Recreation and Fun Next, let’s look at the area of recreation. Perhaps you’ve let go of some things in the area of recreation or you might want to start something new. Take a moment and see yourself at play. Ask yourself, if something new were to happen in your life in the area of recreation, play, or relaxation, what would that mean to you? Try this thought on: I’m a person at play. Listen to these words and just let yourself try each on for a moment: entertainment, sport, vacation, hobby, holiday, leisure, fun, rest. Whatever they mean to you, just allow yourself to settle into the meaning of these things for you and allow your awareness to stretch out into the questions. And gently breathe. Just settle and allow your attention to come gently to rest on your own breath. [Pause briefly.]

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Spirituality Next, let’s look at the area of spirituality. Ask yourself, what is the place of spirituality in your life? Take a moment and see yourself in your spiritual life. If something new were to happen in your spiritual life, what would that mean to you? Try this thought: I’m a spiritual person. Listen to these words and just let yourself try each on for a moment: spirituality, sacred, reverence, ritual, religion, faith, holy. Whatever they mean to you, just allow yourself to settle into the meaning of these things for you and allow your awareness to stretch out into the questions. And gently breathe. Just settle and allow your attention to come gently to rest on your own breath. [Pause briefly.]

Community Life Next, let’s look at the area of community. Community can mean many things—your country, your town, your neighborhood, your church community, a club you belong to. And it can mean many activities—volunteer, neighbor, club member. Ask yourself, what is the place of community in your life? Who are you in the communities you inhabit? Who would you like to be or become? Take a moment and see yourself in your community life. Ask, if something new were to happen in your community life, what would that mean to you? Whatever it means to you, just allow yourself to settle into the meaning of these things for you and allow your awareness to stretch out into the questions. And gently breathe. Just settle and allow your attention to come gently to rest on your own breath. [Pause briefly.]

Physical Self-Care Next, let’s look at the area of health and self-care. No matter your current state of health, let yourself imagine developing and growing in this area. What would it mean to truly care for yourself? Take a moment and try on this thought: I’m a person who takes care of myself. If something new were to happen in the ways you care for yourself, what would that mean to you? What would that look like? Listen to these words: healthy, fit, strong, well, vigorous. Whatever they mean to you, just allow yourself to settle into the meaning of these things for you and allow your awareness to stretch out into the questions. 176

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And gently breathe. Just settle and allow your attention to come gently to rest on your own breath. [Pause briefly.]

The Environment Next, let’s look at the area of the environment. Ask yourself, what role does being a good steward of the environment and of the planet play in your life? What would it be like for you to work for cleaner air and water, a reduction of greenhouse gasses, and more conscientious use of our natural resources? See yourself as a caretaker of the global community. If something could happen in your life that would make it possible for you to care for the planet, what would that be? And gently breathe. Just settle and allow your attention to come gently to rest on your own breath. [Pause briefly.]

Aesthetics Finally, let’s look at the areas of art, music, and beauty. Maybe you don’t enjoy the arts as often or as deeply as you would like. If you could be a part of creating beauty in the world, what could that mean for you? Maybe you would attend more concerts or spend time learning or playing a musical instrument. If you love literature, maybe you would spend time each week with a great book—or start writing one yourself. Let your awareness flow into these possibilities. And gently breathe. Just settle and allow your attention to come gently to rest on your own breath. [Pause briefly.] Let your awareness touch gently each of these areas—family, intimate relations, parenting, friendship, work, education, recreation, spirituality, community, and self-care. And now I’d like to call your attention gently back to your own body here in this room right now. In just a minute, I’m going to ask you to open your eyes and take ten minutes to write about what shows up for you as the most important thing or things in your life, and why this is important and meaningful to you. Write your deepest thoughts and feelings about this area of living. What you write doesn’t have to be grammatically correct. Don’t worry about spelling or even necessarily writing in complete sentences. Please write for the entire ten minutes. If you can’t think of what else you might say, just write the last thing you wrote over and over until something new comes up. When you’re ready, open your eyes and begin writing. 177

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EXPERIENTIAL WRITING EXERCISE Give clients ten minutes in the room alone to write about their values. Give the following written instructions: Please write about some of the domains that we’ve just touched upon and what they mean to you. In your writing, I want you to really let go and explore your very deepest emotions and thoughts. As you write, try to allow yourself to experience your thoughts and feelings as completely as you’re able. This work is based on evidence that pushing disturbing thoughts away can actually make them worse, so try to really let yourself go. If you wish, no one will look at what you write. Although I would prefer it if you leave it here for me to put in your file, you may take it with you after the session. After you write, we’ll talk about what the writing and the exercise brought up.

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Experiential Interview Using HFDEI Worksheets and Rating Scales Complete the experiential interview using the HFDEI worksheets and the HFDEI rating scales. Before describing the interview process below, I’ll introduce the worksheets and rating scales.

HFDEI WORKSHEETS The HFDEI worksheets are a graphical view of the hexaflex model with areas to make notes in each facet of the hexaflex. I currently use the hexaflex for session observation (both live and recorded), for writing case notes, and, finally, for use in this interview. (Below, and in PDF format on the disc that comes with this book, I’ve included one worksheet that was used to code the first seven minutes of the video segment “Emily and Kate: Session 2.” On the disc, look for the file titled “Emily and Kate 2 HFDEI.pdf”). We’ll use these worksheets in the hexaflex diagnostic interview. There’s no difference in application between coding a segment of a session, a whole session, or an intake interview, except that ratings of whole sessions will be more global than you could reasonably make based on a few minutes of a session. The worksheet also contains a place to make numerical ratings for each dimension of the hexaflex. In the examples later in the chapter, I provide a description of observed behaviors in each dimension of the hexaflex and a rating of client functioning in each dimension. The ratings go from 1 to 5, where 1 is given for minimal functioning and 5 is given for optimal functioning. You’ll find both the longer narrative and a brief version of the anchors for these rating scales. Look at the rating scales, look at the video segment, look at the sample hexaflex worksheet, and, finally, look at the case conceptualization below for the worksheet example. I’ve included additional coded hexaflex worksheets and case conceptualizations on the DVD-ROM that accompanies the book; those examples analyze each of the six experiential role play segments.

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CASE CONCEPTUALIZATION OF WORKSHEET EXAMPLE Look at the hexaflex worksheet and watch about the first seven minutes of the video segment Emily and Kate: Session 2. You’ll see on the worksheet that the therapist has handwritten some reminders that would contribute to ratings on the different facets of the hexaflex. The client in the video, Kate, is a thirty-three-year-old woman who is the mother of a small child. She’s a nontraditional college student and reports recurring problems with depression and anxiety. In the current session, the primary concern Kate has revolves around a recent experience in a biology class. She had misspoken in answering a question and felt humiliated in front of her classmates. I’m not advancing the following observations with certitude. Like any case conceptualization, this is a work in progress. Some of the hexaÂ� flex coding that follows, I think, amounts to reasonably sound conclusions. Some of it strays into hypothesis or hunches that I think are well worth probing. Above all, the coding strategy I’ve employed is focused on developing good clinical questions. Good clinical questions make for good clinical answers.

Coding Present-Moment Processes In coding present-moment processes, several features emerge as likely markers of failure of those processes. Most obvious is Kate’s level of rumination. She’s deep in a story about how things went in class and how she shouldn’t have tried to answer. It’s apparent in her presentation that this past mistake dominates her awareness. Even when Emily, the therapist, attempts to make aspects of that memory present by directing Kate’s attention to different details, Kate responds in terms of categories instead of specifics. Kate’s engagement with Emily is thereby diminished. Even when Emily probes, by expressing genuine concern for Kate and by prompting eye contact, Kate is largely uninfluenced by these probes and remains connected to the miserable past event. What is before her, in this moment, is a conversation with someone expressing care and concern. She makes only glancing contact with Emily and with that concern. I see a slight transition, however, toward the end of this segment, when Kate begins describing her experience as it’s occurring in the moment. 180

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In rating this segment for present-moment processes, I’d probably give it a 1, with Kate’s level of contact rising to perhaps a 3 toward the end of the segment. If you listen closely, you’ll hear some softening, an opening to the present moment, though tentative and likely fragile, toward the end of the segment.

Coding Experiential Acceptance Processes In coding experiential acceptance, several behaviors stand out as serving to protect Kate from difficult experiences. Most apparent is her interaction with Emily that I mentioned above, which in the session Kate herself calls “having her guard up.” For example, Kate’s eye contact with Emily is limited to quick, challenging glances, and she interrupts Emily several times to demand explanations for the work they’ve done. Even when Kate is silent, it seems a panicked or at least busy silence, in which she’s planning her defense or offense. Opening up to seeing Emily’s apparent concern for her would likely make her own concern more present, something that she has decided she can’t have. This guardedness doesn’t seem to be totally impermeable, however, as Kate responds to Emily’s request for eye contact by lingering just a moment before returning to her story. I’d rate the segment as a 2 for acceptance processes. Kate is highly avoidant; though, as with present-moment processes, she’s capable with considerable prompting of letting down her guard just a bit.

Coding Cognitive Defusion Processes Several examples of fusion seem to hover in the room throughout this segment. For one, Kate holds tight to the idea that she can’t let her guard down—an idea that she felt was confirmed when letting her guard down in biology class resulted in humiliation. Related is the idea that she can’t look stupid. At the heart of both of these ideas seems to be some fusion with the idea that she may, in fact, be stupid. Kate appears certain that if people really saw her, this is what they’d see. Fusion is also evident in her demands of Emily for justification for the work from their previous sessions that encouraged her to ask the question that got her humiliated. She appears to be fused with the idea that there may not be a reason that justifies her work in therapy because she may not actually be able to be 181

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helped. Other fused ideas include these: “I’m hopeless.” “It is hopeless.” “I was stupid to even try.” I’d rate defusion processes in this segment as a 1. Kate appears quite rigidly fused with her evaluation of her situation and its prospects. There’s little evidence in this brief segment of any softening in the ways those thoughts are organizing her behavior.

Coding Self Processes In the segment, I see interplay between Kate’s avoidance and her fused self-conceptualizations. She guards herself from Emily, which suggests that she sees herself as someone who needs to be guarded. She acts to avoid looking stupid, which suggests that she may see herself as stupid. She describes learning to hide from others and to be silent, which suggests that she may see herself as one who should be hidden and one who has nothing to say. In rating self processes for this segment, I’d give a rating of 1. Kate shows no evidence of a sense of her self that goes beyond her current sense of self-as-failure.

Coding Values Processes Kate seems to value at least one domain in this segment: education. If you take a look at Emily and Kate: Session 1 on the DVD-ROM, you’ll see earlier evidence that this is a valued domain for her. Education is precious to Kate in part because she sees getting an education as part of being the parent that she would choose to be. In the presence of this humiliation and harsh self-criticism, however, Kate exhibits little, if any, connection with either her education value or her parenting value. I’d rate values processes as a 1 for this segment, possibly rising as high as a 2 when Kate begins to open up toward the end of the session. Note how avoidance and fusion leave values virtually invisible. As suggested in earlier chapters, though, it’s worth noting the intimacy between what Kate values and her vulnerabilities. An additional value of Kate’s that I might hypothesize is in the domain of social relations. A potentially fruitful line of inquiry with Kate might be the value and meaning of being seen, appreciated, and included in her learning community. I would wonder what it would mean to her to truly be a member of that community. 182

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Coding Committed Action Processes When I’m coding committed action, I’m interested not merely in the times that a client has successfully committed to engagement in valued living, but also in the ways that the client responds to times that aren’t so successful. This distinction comes out in this session a couple of times. First, Kate has returned to therapy for another session. She undoubtedly knows what difficult things to expect from Emily and from the session, and she shows up anyway. In addition, her avoidance and fusion aren’t entirely consistent, even in this brief segment. Kate becomes increasingly responsive to Emily’s direction to contact her experience more fully. This suggests that Kate may soon notice the inconsistency between remaining fully guarded and her values, and then turn gently back toward living her values. I’d rank this segment as a 2 for commitment. Although there’s considerable fusion and avoidance around making and keeping commitments, she did show up for the session. This amounts to commitment with one’s feet. Questions about this domain might include these:

• What might commitment look like for someone with your doubts and with this hard week ringing in your experience?

• What would a tiny committed act look like? • Is being here today part of that commitment? Kate’s response to these questions might provide part of the treatment for her fusion, as she generates even small samples of commitment. After all, generating a commitment is part of commitment.

HEXAFLEX ANCHORS

Present-Moment Process Narrative Anchors A SCORE OF 5 The client exhibits connection with his experience in the present moment both when speaking and when listening to another. The pace, rhythm, intonation, volume, and content of the client’s speech are fluid and flexible. Pace rhythm, intonation, volume, and content are readily prompted. The client’s posture, facial expression, eye contact, and 183

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Â� gestures facilitate connection with what the current contents express, on the part of both the client and the listener. Even when the content is focused on the past or on the future, the client is connected with its moment-to-moment expression. Speech content is frequently specific and detailed. The client readily provides specifics and details when prompted, and speech that is uniformly categorical is uncommon. The client gently shifts attention between aspects of his experience, maintaining or quickly regaining his connection with his experience. The client is able to identify when he’s not connected to his experience in the present moment, and to precipitate that connection independently. The client reliably reconnects with his experience in the present moment when directly prompted. Worry and rumination are rare.

A SCORE OF 3 The client exhibits inconsistent connection with her experience in the present moment, perhaps having difficulty only when listening or only when speaking. The pace, rhythm, intonation, volume, or content of the client’s speech may sometimes shift into stereotypy. Instructing change from stereotypies is possible, but shifts back to sterotypies are common. The client’s posture, facial expression, eye contact, or gestures sometimes prevent connection with the listener. The client sometimes has difficulty staying connected in the present moment with expression of content, especially when content is focused on the past or the future. Speech is frequently categorical and lacking in specific and detailed content. The client responds to directions to provide specifics and details, but her speech frequently shifts back to categorical mode. The client sometimes perseverates on particular aspects of her experience and may sometimes shift attention abruptly, losing connection with her experience. The client usually reconnects with her experience in the present moment when directly prompted but rarely notices when she’s not connected. The client is unlikely to reconnect without prompting. Worry and rumination are somewhat common.

A SCORE OF 1 The client exhibits almost no connection with his experience in the present moment, either when listening or when speaking. The client’s speech almost always takes on marked stereotypy with respect to pace, rhythm, intonation, volume, or content. The client’s posture, facial expression, eye contact, and gestures almost always prevent connection with the listener. The client almost always has difficulty staying 184

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� connected with expression of content that is focused on the past or the future. Speech is almost always categorical and lacking in specific and detailed content. Response to directions to provide specifics and details are short-lived, and his speech almost always shifts back to categorical mode. The client almost always perseverates on particular aspects of his experience, and shifts are almost always abrupt. The client rarely reconnects with his experience in the present moment when directly prompted, and may actually become more disconnected. Worry and rumination are common.

Present-Moment Process Abbreviated Anchors

1â•…2â•…3â•…4â•…5 Speech stereotyped and insensitive to instruction for pace and content

1

Speech fluid and 5 sensitive to instruction for pace and content

Physical presentation takes 1 away from connection

5

Physical presentation adds to connection

Worry and rumination common

1

5

Worry and rumination rare

Perseverates and shifts abruptly

1

5

Shifts attention easily and gently

Categorical speech common, details difficult to elicit

1

Categorical speech 5 uncommon, details readily elicited

Doesn’t notice when not present

1

5

Notices when not present

No change or less present 1 with direction

5

More present with direction

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Self Process Narrative Anchors A SCORE OF 5 The client describes and experiences herself in a variety of ways without being attached to any particular diagnosis, symptom, thought, emotion, positive or negative self-evaluation, social role, personality trait, physical characteristic, or other conceptualization, independent of its veracity or falsity. The client transitions easily and appropriately from one content area to the next as the situation demands. This flexibility among self-conceptualizations fosters contact with an experience of herself apart from those conceptualizations. The client is able to contain and readily connect with any aspect of experience even when content is difficult. She can readily take different perspectives when prompted and may take different perspectives spontaneously.

A SCORE OF 3 The client describes and experiences himself in a variety of ways but frequently becomes attached to particular diagnoses, symptoms, thoughts, emotions, positive or negative self-evaluations, social roles, personality traits, physical characteristics, or other conceptualizations, especially when content is difficult. The client sometimes has difficulty transitioning among content areas as the situation demands, even when prompted, and may act ineffectively in certain situations as a result. The client rarely contacts a sense of himself apart from self-�conceptualizations. The client sometimes allows conceptualizations of himself to limit activities. He can take different perspectives with difficulty when prompted and rarely takes different perspectives spontaneously.

A SCORE OF 1 The client describes and experiences herself in very limited ways, and repeatedly becomes attached to particular diagnoses, symptoms, thoughts, emotions, positive or negative self-evaluations, social roles, personality traits, physical characteristics, or other conceptualizations with little or no awareness of self independent of that which is currently occupying her awareness. The client rarely transitions among content areas as the situation demands, even when prompted, and often acts ineffectively as a result. The client’s activities are severely limited by

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Â� conceptualizations of herself. She can’t take different perspectives even when prompted and doesn’t take different perspectives spontaneously.

Self Process Abbreviated Anchors

1â•…2â•…3â•…4â•…5 Experience of self constrained and in only limited domains

1

Experience of self 5 flexible and broad

Frequently gets stuck in content areas

1

5

Transitions easily among content areas

No experience of self apart from content

1

5

Experiences self apart from content

Rarely able to shift perspectives

1

5

Readily able to shift perspectives

Defusion Process Narrative Anchors A SCORE OF 5 The client almost always experiences a full range of thoughts, beliefs, emotions, and evaluations without any aspect of experience dominating control of his behavior, except where such focus is chosen. Stories about how the world is (for example, about the future, the past, others, or relationships) are held lightly. Stories are rarely rigidly repeated. When the client does lapse into such stories, he readily recognizes this and lets go of the story. He infrequently uses exclusive language such as must/can’t, should/shouldn’t, always/never, or right/wrong. The client experiences and describes his experiences without judging, justifying, or explaining. He chooses assumptions strategically because they facilitate valued living. The client approaches new experiences openly, with expectations and rules derived from prior experiences held lightly.

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A SCORE OF 3 The client’s experience of events is sometimes limited by particular thoughts, beliefs, emotions, and evaluations that dominate control of her behavior. This domination isn’t experienced as chosen. Stories about how the world is (for example, about the future, the past, others, or relationships) are sometimes held rigidly. Stories are sometimes rigidly repeated, but the client moves to another topic or aspect of experience when directed. She sometimes uses exclusive language such as must/ can’t, should/shouldn’t, always/never, or right/wrong, especially in the face of difficulties. The client sometimes judges, justifies, or explains her behavior. She shows occasional sensitivity to the workability of beliefs but is frequently sensitive only to the true/false aspects of belief. The client approaches new experiences with relatively rigid expectations and rules for behavior, which sometimes persist even if they aren’t consistent with the new experience.

A SCORE OF 1 The client’s experience of events is almost always limited by particular thoughts, beliefs, emotions, and evaluations that dominate control of his behavior. This domination isn’t experienced as chosen. Stories about how the world is (for example, about the future, the past, others, or relationships) are held rigidly and often repeated. The client doesn’t move to another topic or aspect of experience, even when directed. There is much use of exclusive language such as must/can’t, should/shouldn’t, always/never, or right/wrong, especially in the face of difficulties. The client frequently judges, justifies, or explains his behavior. He shows little or no sensitivity to the workability of beliefs and is sensitive only to the true/false aspects of belief. The client approaches new experiences with rigid expectations and rules for behavior, which persist even if they aren’t consistent with the new experience.

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Defusion Process Abbreviated Anchors

1â•…2â•…3â•…4â•…5 Single aspect of experience dominates without choice

1

No single aspect of 5 experience dominates, except by choice

Frequently judges, justifies, or explains

1

5

Frequently uses must/ can’t, should/shouldn’t, right/wrong, and so on

1

Rarely uses must/can’t, 5 should/shouldn’t, right/ wrong, and so on

Expectations and rules limit perspective

1

5

Expectations and rules held lightly

1

5

Stories seldom repeated rigidly

Stories repeated rigidly

Little or no sense of workability of thoughts 1

Rarely judges, justifies, or explains

Chooses assumptions 5 strategically, with a focus on workability

Acceptance Process Narrative Anchors A SCORE OF 5 The client embraces the full range of experience and only rarely attempts to change the frequency or intensity of associated bodily states, emotions, thoughts, perceptions, urges, cravings, or memories. The client rarely insists that an aspect of experience that’s difficult must be eliminated, or conversely that some desired state must be obtained. The client frequently experiences and describes difficult experiences in session with appreciation for their richness and gravity. The client almost always engages easily and openly, and her presentation rarely seems to be implicitly requesting attention, permission, approval, pity, condemnation, abandonment, or some other social exchange. The client reports and shows willingness to experience internal and external events in service of valued living and often freely chooses such experiences. The 189

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client notices when she’s engaged in avoidance in session and opens up to her experience independently or is reliably responsive to instruction to do so.

A SCORE OF 3 The client sometimes embraces the full range of experience, but this may occur only with direct instruction, for a limited amount of time, in particular situations, or for less difficult experiences. The client sometimes attempts to change the frequency or intensity of associated bodily states, emotions, thoughts, perceptions, urges, cravings, or memories. The client sometimes insists that an aspect of experience that’s difficult must be eliminated, or conversely that some desired state must be obtained. The client experiences and describes difficult experiences, but sometimes in a manner that’s minimizing, rationalizing, or otherwise disconnected. The client engages easily and openly at times, but at other times presents implicit requests for attention, permission, approval, pity, condemnation, abandonment, or some other social exchange. The client reports some internal or external events that he isn’t willing to experience. The client may choose some difficult experiences, but this is sometimes in the form of tolerance or resignation rather than acceptance. The client usually opens up to his experience when directly prompted, but rarely notices independently that he’s engaged in avoidance.

A SCORE OF 1 The client rarely embraces the full range of experience and never or rarely without direct instruction. The client often attempts to change the frequency or intensity of associated bodily states, emotions, thoughts, perceptions, urges, cravings, or memories. The client frequently insists that an aspect of experience that are difficult must be eliminated, or conversely that some desired state must be obtained. Difficult experiences are often described in a manner that’s minimizing, rationalizing, or otherwise disconnected. The client rarely engages easily and openly, often presenting implicit requests for attention, permission, approval, pity, condemnation, abandonment, or some other social exchange. The client reports many internal or external events that she’s not willing to experience. The client rarely chooses difficult experiences, and when she does, it almost always takes the form of fighting, tolerance, or resignation rather than acceptance. The client rarely opens up to her experience when directly prompted to do so and may actually become more avoidant. 190

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Acceptance Process Abbreviated Anchors

1â•…2â•…3â•…4â•…5 Attempts to change experience common

1

5

Minimizes or rationalizes difficult events in session

1

Describes and 5 experiences difficult events in session

Implicit requests for social 1 exchange Many avoided events

1

Fights, tolerates, or resigns to difficult experiences 1

5 5

Attempts to change experience rare

No implicit requests for social exchange Few avoided events

Chooses difficult 5 experiences in service of valued living

Does not notice when avoiding

1

5

No change or more avoidant with direction

1

5

Notices when avoiding More open with direction

Valued Living Narrative Anchor A SCORE OF 5 The client maintains an open posture with respect to values even in the face of psychological pain. He freely, actively, and intentionally chooses life directions. His behavior is only rarely organized rigidly by thoughts and evaluations regarding values. The client expresses a sense of vitality and purpose in values even when describing painful events. Values are held flexibly and without defense, in a way that’s sensitive to needs in other domains of living. The client notices and describes a variety of behaviors that could be chosen in service of a valued direction. The client’s behavior is almost always in service of this direction, even when outcomes are expected to be difficult or unknown. The client almost always describes his chosen values and degree of valued living 191

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openly and without judging, justifying, explaining, or apologizing. The client usually experiences his values as facilitative of experience rather than restrictive or burdensome.

A SCORE OF 3 The client chooses direction for her life, but this is sometimes limited by what is perceived as possible or painful. She expresses a sense of vitality and purpose in values but is less likely to do so when describing painful events. Values are sometimes held defensively and rigidly, even when doing so has negative consequences in other domains of living. The client notices and describes a somewhat limited number of behaviors that could be chosen in service of a valued direction. The client’s behavior varies in how consistent it is with pursuing this direction, and is often inconsistent when outcomes are expected to be difficult or unknown. The client sometimes describes her chosen values and degree of valued living with limited openness, as evidenced by judging, justifying, explaining, or apologizing. The client sometimes experiences her values as facilitative of experience and but also frequently as restrictive or burdensome. When directly prompted, the client can sometimes let go of limitations and make contact with values in an undefended way—her stories loosen and she shows lessening signs of fusion and avoidance.

A SCORE OF 1 The client rarely chooses direction for his life in an active and flexible way. Most valuing is described as driven by circumstances and much less by personal choice. He professes no sense or a weak sense of valued direction; describes valued domains with rigidly held preordained conclusions about outcomes; or professes strong confusion about values. All of these presentations are held rigidly even when directly probed. The client expresses a sense of hopefulness and direction in values almost exclusively when things are going well. This sense of direction is readily lost when he’s confronted with painful events. When values are held, they are almost always held defensively and rigidly. Behavior shows insensitivity to costs in other domains of living. The client resists discussions of values and does so only with excessive judging, justifying, explaining, or apologizing. He almost always experiences values as restrictive, burdensome, impossible, or confusing, or with rigid enthusiasm.

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Values Processes Abbreviated Anchors

1â•…2â•…3â•…4â•…5 Valued directions rarely chosen, and limited by possibility and pain Valued directions chosen with defensiveness Valued directions held at the expense of other domains Few behaviors described as values consistent

1

Valued directions 5 chosen freely, regardless of possibility or pain

1

Valued directions 5 chosen without defensiveness

1

Valued directions held in a way that doesn’t 5 interfere with other domains

1

A variety of behaviors 5 described as values consistent

Behavior more consistent with expectations for 1 outcome

Behavior consistent, even when outcome 5 unknown or expected to be painful Discusses values and valued living openly

Resists discussing values and valued living by 1 judging, justifying, explaining, or apologizing

5

Experiences values as aversive and restrictive of experience

Experiences values as 5 appetitive and facilitative of experience

1

Committed Action Processes Narrative Anchors A SCORE OF 5 The client almost always remains flexible and creative in her pursuit of chosen valued directions, even in the face of disappointing or frustrating outcomes. The client willingly chooses short- and long-term goals 193

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that are experienced as consistent with her values. The client can see and select from many potential goals, both small and large, that are consistent with her chosen life direction. The client notices when her behavior is inconsistent with valued directions independently and without defense, and returns gently and with intention to commitments. The client is responsive to direct instruction to notice inconsistency, and is able to sit undefended in the face of inconsistency and return gently and nondefensively to commitments when necessary.

A SCORE OF 3 The client’s behavior in valued domains sometimes involves attempts to relieve difficult thoughts and feelings through inaction, impulsivity, or persistence despite ineffectiveness in pursuing values. Periods of inactivity are sometimes followed by activity that serves to undo and defend the client from periods of inactivity. The client sometimes responds to disappointing or frustrating outcomes by questioning his values or capacity to commit, and has some difficulty generating goals that are consistent with his values. The client can sometimes generate an array of goals small to large, but at other times becomes attached to particular forms of behavior as the only goal consistent with his values. The client sometimes notices when behavior is inconsistent with valued directions independently but may be somewhat defensive or, by contrast, ruminative about failures, making it difficult for him to return to commitments, even with instruction.

A SCORE OF 1 The client’s behavior in valued domains is almost always dominated by attempts to relieve difficult thoughts and feelings through inaction, impulsivity, or persistence despite ineffectiveness, or by lurching into periods of activity. She may actively avoid making commitments or speak about commitments in the language of must/can’t, should/shouldn’t, and never/always. She has great difficulty generating goals that are consistent with her values. The client is unable to generate a range of large and small goals, and experiences the goals she does generate as the only goals consistent with her values. The client is frequently insensitive to times when her behavior is inconsistent with valued directions or she becomes rigidly fixed on her failure to maintain commitment. Direct instruction to notice the inconsistency and return to valued living is usually unsuccessful and may actually bring the client further away from valued living by precipitating rumination and worry. 194

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Committed Action Processes Abbreviated Anchors

1â•…2â•…3â•…4â•…5 Behavior in valued domains characterized by 1 avoidant inaction, impulsivity, or persistence

Flexible and creative in valued living

5

Difficulty generating goals, and goals limited and inflexible

1

Chooses values5 consistent goals easily and freely

Rarely notices inconsistency of behavior with values

1

Notices inconsistency 5 of behavior with values

No change or further from valued direction with 1 instruction

Returns to valued 5 direction with instruction

Much rumination and worry about commitments 1

Little or no 5 rumination about commitments

AN EXPERIENTIAL WAY FORWARD It would be inconsistent with the core ACT model to imagine that information alone won’t move clients but will move therapists. Merely understanding the phenomena above—knowing that they exist and what they look like—isn’t likely to have profound effects on your own behavior as a therapist. In the preceding pages, I offered you some moment-by-moment patterns that are common ways we lose contact with the present moment and diminish our effectiveness. As with clients, the most potent intervention won’t be the gathering of information. ACT is an experiential approach to behavior change. It’s the rich interaction of information with experience that will make us more effective as therapists. In the next chapter, I’ll outline a set of exercises that you can do to make experiential contact with your own barriers to being fully present 195

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to clients. The exercises are an essential part of the approach. They provide an opportunity to learn about and practice ACT principles. The impact of the exercises will be twofold. First, they’ll soften your approach to clients. If you can open up to your own deepest fears, breathe them in and out like air, and sit with them in kindness until running isn’t necessary, you’ll have much more heart for the hard things you ask your clients to do. Second, if you can meet your worst fears with equanimity, you’ll be able to sit in the presence of your clients in a way that opens you up to the subtle ebb and flow of their behavior and thereby put yourself in a much more effective place from which to work on their behalf.

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Making Experiential Contact with Mindfulness

Simple information about what keeps you and your clients from the present moment is of extremely limited use. Before jumping from a boat and swimming to shore, you might know that you need to learn how to swim. However, knowing is not swimming. Swimming comes from practice at swimming.

THE POVERTY OF KNOWING Knowing just isn’t enough. Making the sort of discriminations that I’ve been describing throughout this book will take practice. Some of the practice will involve watching and listening to sessions with clients and actually making these discriminations. But central to what I’ve been writing about here are the discriminations you’ll need to make in your own behavior. In order to do this, you need to somehow create experiential preparations that allow for close examinations of ACT processes within structured interpersonal interactions. Throughout the text, I’ve offered little exercises to help you make contact with ACT-relevant processes. In this chapter, these exercises move solidly into the realm of the interpersonal. Because these processes, as they play out in interpersonal

Mindfulness for Two

interactions, are central to the doing of therapy, this might be the most important chapter of the book. It contains far less information than any other chapter, but far more training experiences that provide a place to put those principles into practice. What follows is a series of three exercises. They begin with a very simple one, Sweet Spot, in which the content is pleasant and your activities are pretty limited. The next exercise, Client Descending, involves painful content but still a quite limited set of activities. Finally, I’ll introduce the Experiential Role Play, where the content is difficult and the interaction is decidedly more complex. I’ll describe several variations on the Experiential Role Play Exercise, including its use as a way to learn and do case conceptualization in an experiential context. All of these exercises require at least one other therapist. Ideally, you’ll have a total of three or four therapists working together in order to get the most from the Experiential Role Play. It’s fair to warn you that you won’t like the restrictions I place on your behavior during these various exercises. The exercises are a special preparation that makes processes apparent that are typically invisible to us. Just as in medicine, where tissue stains and dyes can sometimes bring physical features into high relief, these exercises are designed to bring psychological processes into sharp, bold resolution. For example, in Sweet Spot and Client Descending, I impose turn taking, and silence for the partner who’s not speaking. There’s no question-Â�and-answer exchange allowed in these two exercises. Likewise, I restrict other nonverbal social exchanges, such as nodding and smiling. I also restrict problem solving in both of these exercises. Finally, I’ll impose hesitations and silent pauses into the exchanges. In the third exercise, the Experiential Role Play, I allow questions and answers, but I enforce adherence to the assigned role (either therapist or client) and restrict stepping outside of the role during the exercise. I also impose periods of silence. I promise that you’ll find these impositions intrusive and uncomfortable. And I implore you to hold to them. If you don’t for some reason, a good deal of the exercise’s potential for instruction will simply vanish. These role plays have been road tested on literally thousands of therapists and will do their work. Try the exercises as described. Hold to the structure of the exercise. If you find over time that you wish to modify them, feel free to do so, but give them a try as is before you do.

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ENTERING A DIFFERENT SORT OF CONVERSATION What I want with my clients are significant conversations, conversations that can change lives—both theirs and mine. When I say “change,” I don’t mean from something “bad” to something “good”—from a “bad them” to a “good them,” from a “bad life” to a “good life.” We have but one life—this life, this very life. Conversations about whether a life is good or bad or whether a person is good or bad or worthy or unworthy don’t interest me much. Back and forth they go, but to what end? I haven’t noticed these conversations taking me nor my clients anywhere. Ordinary conversations come so naturally to us. One doesn’t need a therapist to have one of these conversations. Step into any bar. Buy the person next to you a beer. Complain about something, almost anything really. See if he isn’t willing to join you in that complaint. “Oh, you think your boss is bad!” “Well, then my wife said…” “Nothing ever really goes right for me either.” And on and on. If your newfound companion doesn’t join you in your misery, he’ll almost certainly favor you with a hollow reassurance that things will get better. Ask him not so kindly for an alternate view, and he’ll start giving advice. The conversations differ in comfort level but little in function. Perhaps you can recall certain conversations you’ve had in your own life, though, that shook you, that altered your fundamental relationship with the world around you. Perhaps the conversation we’re having right now could be like that. Perhaps the next conversation you have with a client could begin such a process. I’m not shy about telling clients that I’m interested in life-changing conversation with them. Part of the task at hand will be to distinguish two kinds of conversations. One type of conversation is all about limitations—Â�conversations about what can be expected, hoped for, imagined, about what is realistic or deserved or could be gotten away with. But don’t you want more than that? Don’t your clients long for more? There’s a second kind of conversation. It’s a conversation about possibilities. It’s a conversation about that which we long for but perhaps can’t even name—a sometimes inscrutable more. We’re not used to more, except in the crude material sense. We’re used to wanting more house, more car, more money. Even when we want more of nonmaterial things—to be

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loved, understood, appreciated—the more often has a clutching quality that’s not unlike the desire for a new car. There’s little outside of religious conversations, though, that fosters a careful discernment of the direction one’s life might take. Even in religious conversations, such direction is too often formulized. I’m interested in conversations within which we can hear the resonance of the very world and the resonance of our own lives in that world—conversations in which we can hear, really hear, the depth of love that has gone unspoken, perhaps even unfelt, the dreams and desires that remain tucked away—significant conversations. These exercises provide a simple, but not easy, way into such conversations.

THE SWEET SPOT EXERCISE “Think of a moment in your life that was sweet.” Sounds simple enough, right? This exercise involves two participants who exchange the tasks of speaker and listener. You can do it with up to four people if two of them take the role of witnesses, unnerving people whose job it is to silently observe the speaker and listener exchange. The addition of witnesses to the exercise is a recent one, which I think changes the dynamic of the exercise dramatically for the better. If you can, I strongly urge you to try the exercise with witnesses. For content, I ask participants to think about a specific sweet moment in their own lives, past or present. The exercise involves a meditation on this sweet moment followed by a period of speaking and listening in turn. The purpose of the exercise is to cultivate mindfulness for two in a very simplified interpersonal interaction. A script for the induction, or introductory phase, for this exercise follows. I didn’t include a script of anyone’s sweet spot. You can easily supply that yourself, and there’s a complete video clip of the exercise included on the disc that comes with this book. Also, there’s an audio recording on the disc that you can use in a practice group to conduct the exercise. If you do try the exercises with the audio recording, make a point of honoring the instructions to pause and let your voice fall away. When I lead this exercise in workshops, I break up the conversation at random intervals—and I’m very strict about not letting the conversations continue when I do. The disc is actually very faithful to the live experience in this respect. 200

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Sweet Spot Exercise Structure The basic structure of the exercise follows. A more elaborated description of the structure and of what I’m looking to find in the moment of sweetness can be found in the script of the exercise below. 1. Introduce the idea of a sweet spot. 2. Get participants paired up. If you have witnesses, the witnesses should sit directly across from one another and the speaker and listener should likewise be sitting directly across from one another. The participants should face each other directly. They should sit near one another to hear even if speech becomes quite soft. 3. Instruct the roles for speakers, listeners, and witnesses. 4. â•›Listeners: The job of the listener is to simply appreciate the sweetness that’s being expressed. In chapter 1, I spoke of clients as sunsets versus math problems. In this exercise, the pitfall for the listener will be to try to understand what the speaker is describing. I will ask, for the purpose of the exercise, that you let go of understanding. You may pick understanding up again later. For now, when you find yourself trying to understand, just gently let that go for the time being. Your job is just to observe this sunset before you—a human being in the simple act of expressing sweetness. 5. â•›Speakers: The pitfall for the speaker will be to explain why something is sweet. No explanation is needed. You should let go of explanation when it arises and gently return your attention to your own experience of sweetness and to letting that sweetness pour forth. What we’re after is not explanation, just expression. Allow yourself to be a sunset. Let the listener be an observer of that sweetness you have known. I’ve done this exercise with people speaking different languages and it remains effective. Gently let go of concerns about being thorough or coherent. 6. â•›Witnesses: The task for the witnesses is to watch the pair of sunsets before you. Allow yourself to notice the ebb and flow of the presence of both the speaker and listener. Witnesses will be prey to the same comings and goings as the therapists 201

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and clients. When you find yourself in analysis land, gently return to the interaction. Appreciation is the core task. Because of the intimacy of the exchange between speaker and listener, witnesses may feel inhibited in looking directly at the speaker and listener. Please gently notice that reluctance and allow yourself to watch. You’ll see subtle shifts, and we want to cultivate an appreciation for those shifts. 7. Decide in advance who will be the first speaker and listener. There are no breaks during the exercise. Transitions from one speaker to the next are not punctuated by conversation or debriefing. Protect the quiet state between shifts in role. 8. Get participants settled in and then lead the Sweet Spot Exercise. 9. Have participants open their eyes gently and in silence. 10. Instruct the first speaker to begin speaking. Caution him to intentionally bring a very slow, mindful pace to his expression of sweetness. 11. Stop the speaker after a couple minutes. Have him rest in silence for a few moments, notice the busyness of his mind, pause again, and come even more gently back to the task. 12. Stop the speaker again and have both speaker and listener allow their eyes to close. Take about two minutes during which the speaker, listener, and witnesses (if any) rest in the sweet moment. 13. Have the speaker and listener switch roles and repeat the process above. 14. Debrief using the debriefing instructions that follow the exercise below. If you’re leading this exercise, you should read the exercise slowly, mindfully, and gently. Listen to your own words one by one. Pause regularly and let your own words settle around you. It will help you catch up with yourself. It will help you to set the pace for the exercise. Also, do note that the script that appears below is not a word-for-word transcription of the guided audio that appears on the disc. 202

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The Sweet Spot Exercise Script I’m going to lead you in a little eyes-closed exercise. I’ll ask you to bring your attention to a sweet spot in your own life. So let me give you an example. It can be a very simple sort of thing. [Use your own example of a sweet moment. Let yourself settle into it even as you tell about your sweet moment. Allow yourself to be saturated by that moment in each word of its expression.] An example I’ll give is something I experienced with my thirteen-year-old daughter. For those of you who have teenagers or grown children, you know what I knew during this sweet moment—that the writing was on the wall. Other people were going to start to be much more interesting than me at any minute. So in my moment of sweetness, I’m savoring those last drops of being the apple of my daughter’s eye. On Sunday mornings a long time ago, my family and I used to sit with a congregation of Quakers. The children would sit with the adults for the first ten minutes or so before going off to children’s meeting. I would sit in the big easy chair in the corner and my daughter would plop down on my lap and lay her head on my chest. She is freshly showered and I can smell her hair as she’s sort of nestled there. There’s no place to go. I can feel her—you know, close to me there. Sometimes it’s just the best ten minutes of my whole week. It’s just perfect. There is nothing that moment needs. That moment is complete. So I’ll ask you to think about some sweet spot. It doesn’t have to be like mine. It can be some thing very simple. But think about something specific—a specific instance of something sweet. It could be like your first cup of coffee in the morning, like on Sunday morning when you lay out the paper and take that first sip. Or it could be anything—like watching a sunset or paddling a kayak. Sometimes when you’re watching your kids as they play, there are these times when they completely don’t see you watching them, and you really see them. I would like to invite you to encounter that sweet moment. And then I’m going to ask you to open your eyes. You’ll be sitting across from your partner. There are going to be two jobs that you do. The first job is to just express this sweet moment, to just give voice to it. Here’s one of the problems that will show up for you. Like I said, you’ll encounter problems. The problem here will be that you’ll want to explain yourself. Like you’ll think, I’m not really explaining myself so that the listener really gets how sweet this is for me. You’ll want to solve that problem. So if you find yourself doing that, you have the same job you would have, say, if you 203

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notice yourself making a grocery list while doing sitting meditation. Your job is to notice that and then gently come back to your breath. Here you’re just giving voice to this sweet moment, letting it pour from you. Just like you took a glass of water and let that water pour out. Just like that. If there’s any effort involved, just notice your efforting, and just let yourself go silent and come back to giving expression to your sweet moment. Your partner’s job is to appreciate. And for appreciators, the pitfall is trying to understand. And another pitfall is trying to make sure that the expresser understands that you understand. Appreciators will want to nod—like “I get it,” “Really,” “Right.” Because think how uncomfortable the expressers would feel if they didn’t get that you got it. You know, here they are telling you about this wonderful thing, and it just goes in one ear and out the other. How awful would that be for them? So you’ll feel inclined to solve that problem by reassuring them that you understand. I want you to notice how much you feel like you have to nod and smile. There’s nothing wrong with scratching if you have an itch. But there’s something that shows up in a meditation if you don’t itch that scratch—if you just notice it, if you say yes to it. So I’m going to ask you to just say yes to these things that will show up for you. You might say to yourself, I don’t know if I really get this. And then you’ll try to noodle it out. If you find yourself efforting and trying to understand, just notice that. Notice the efforting and then gently bring yourself back to the person who’s sitting across from you. Just like watching a sunset. You don’t need to evaluate it. You don’t need to understand. How many people understand the physics of light refraction? Not so many. But are you able to appreciate a sunset? Sure. I’m going to ask you to go silent. No talking in between here. We can talk later. Just sit and be with the person across from you. After a while, I’ll ask the next person to go. When I do, you just switch jobs. Then I’ll ask you to go silent again. I don’t want any conversations to intervene here. I’ll ask you to just sit with the person for a moment. Then I’ll ask you to acknowledge your partner and we’ll come back together again. Okay, so let’s occupy the room. Now during this session I’m going to be coaching you. I can almost assure you that another problem will occur. You’ll think, Gee he’s annoying. I was really doing well here, but now he’s bothering me. If you notice that, just notice it and come back to your task. I’m going to ask you to stop talking at certain points, but you won’t be done, and that will present itself as a problem. I want you to just notice that and come back to your task. So if you’re expressing and I ask you to stop and let yourself grow silent for a moment, and you notice the

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thought But I’m not done, then just notice that and let the expression continue even though the words stop. Allow yourself to sit comfortably—maybe with your feet on the ground. You won’t need any paper of pencil or anything like that. Just gently, gently let your eyes close. I’d like you to begin by noticing the different sounds in the room. Imagine that you have a sort of checklist. Begin with the most prominent sounds, and just as you notice them, imagine that you check them off the list. See if you can listen for smaller more subtle sounds. You might hear the sounds of vehicles outside, the sound of a jackhammer. If you listen carefully, you might hear the sounds of people around you. Breathe. Begin to draw your attention to your own body. Slowly begin to notice the place where your body makes contact with the floor, with the chair. And breathe. Notice especially the little places where you can feel the transition in that contact, the very edges of the place on your back that’s touching the chair. See if, in your mind’s eye, you can trace that very edge. See if you can begin to notice the very small details in sensation that tell you this part is touching, that is not. And breathe. And now I’d like to draw your attention to your own hands. I’d like you to start to notice the temperature of your hands. Maybe you can notice that some places on your hands are a little warmer than other places. See if you can notice the little details of sensation of those transitions from places that are little warmer to places that are a little cooler on the skin of your own hands. And breathe. See if you can notice the sensation of your blood pulsing in your hands. Notice just where in your hands you can feel that. Now I’d like you to take just a couple of nice slow breaths where you notice the details of the inflow and outflow of your own breath. Let your lungs fill completely and empty completely. Now I’d like you to imagine that in front of you there is a file cabinet. Now imagine that you open the drawer and reach in and withdraw a picture—a picture of you during that sweet moment. Let yourself draw that picture up from the file cabinet and feel it in your hands. Let yourself look into that face of yours in that picture and let yourself notice the details surrounding you. Notice the look on your face. And now I want you to imagine as if your awareness were some sort of liquid that could be poured into that you in that picture. So imagine that now you are beginning to pour into the skin of that you in that picture at that very moment. See if you can let yourself emerge in that place at that particular moment. You can imagine opening your eyes in that place and kind of let yourself see what you see there. Let yourself notice the sensations that you feel on your own skin in that place. If you’re outdoors, 205

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perhaps you feel a slight breeze. If you’re with someone, you might feel the warmth of his skin against you, the scent of her hair. Let it be as if you could just breathe that moment in, as if each breath just filled you with the sweetness of that. Let it be as if every cell in your body can feel what it is to be in that place. Just take a moment to luxuriate in that presence. And now I’m going to ask you to gently, gently let your eyes open. I don’t want anyone to speak yet. Let yourself look into the eyes of that person who is sitting across from you and let yourself notice that there is a person sitting right across from you who has known sweetness. Just look into those eyes, and see if you can see not the person present but the person who has known sweetness behind those eyes. Now the person who is going to go first, I want you to just gently let that sweetness fill you up slowly like some liquid, and when you’re ready, I want you to gently, gently begin to speak and give expression to that. Let the person across from you hear, feel, and see that sweet moment. Stay with it. The person who is appreciating, there is something there. Just notice the color and nuance of it. [Expression begins.] Now I’m going to ask you to gently grow silent, but see if you can just let that sweetness continue to pour from you. Look in these eyes across from you. Now we’re not going to switch yet. I’m going ask the same person to start speaking, but before you start, I want you to notice if there was any urgency to explain yourself, any push, any effort. I’ll ask you to gently notice that and let go of that effort. And the same person again just gently come back to that expression. Just let it come from you. Just let it flow. [Expression resumes.] Once again, gently, gently let yourself go silent. Look once more into the eyes of the human being across from you who has known sweetness. Now I’m going to ask you to gently close your eyes for just a moment. The person who was appreciating, I’ll ask you to recall that sweet moment of your own. Just let yourself see it. And let yourself be poured into that moment until you can feel it in your very skin and your breath. And then, when you’re ready, just gently, gently open your eyes and look into the eyes of that human being across from you. I want you to go gently as if you were walking through a forest. If you walk very quietly, you might see things that you would miss if you hurried. So in the gentlest way you can, just let that sweet moment be expressed. [Expression begins.] Now I’m going to ask you to pause. Just let that sweetness fill you. Let it pour from you with no words. Listeners, stay with your partner’s eyes. There is a person there who has known sweetness right there. There she is. Then I’ll ask you to gently come back to the task. Just let it come. If you notice any 206

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effort at all, see if you can let go of that. And if you’re appreciating and you find yourself trying to understand, see if you can just let go of the trying and just let the moment be poured forth into you as if you are a vessel. So gently come back to it. [Expression resumes.] I’ll ask you to just gently, gently let yourself grow silent. Just take a moment and look into the eyes of that human across from you. Look at the person behind those eyes who has known sweetness like you, who has known life. Just look a moment into those eyes. Behold. [Pause for a few moments.] Now gently acknowledge your partner, and we’ll start our debriefing.

Debriefing the Sweet Spot After completing the exercise, debrief it as follows. There should be no break between the exercise and the debriefing. Come very gently to the debriefing. Don’t rush. Let your words come one at a time and attend carefully to your pacing. See if you can bring that mindful posture into the debriefing. Especially watch your transition through the questions. Read the question and then take a moment of silence to sit inside the question before you begin to answer. Notice your own urgency to get on with it. 1. Take a few minutes and focus your attention directly on your experience. If you notice any theoretical analysis appearing in the conversation, please let go of that and come back to the experience. a. What was the quality of your experience with your partner? b. What impact did the exercise have on your sense of connection with your partner? Do you feel closer to or further from your partner? c. Did you have the experience, even momentarily, of truly being seen—the experience of being a sunset rather than a math problem? d. Did you have the experience, even momentarily, of truly seeing another person—the experience of seeing a sunset rather than a math problem? 207

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e. How was that experience? f. How common is that experience in your life? 2. Next, we’re going to look at the experience through the lens of the hexaflex. Again, gently breathe. We’ll bring mindfulness to analysis. It can be done. Just slow, slow down. Go gentle. If you find yourself being caught in the analysis, noticing that hook is part of the exercise. Whichever partner notices, please make a quiet request for a mindful moment. Let go of analysis and come gently to your breath, even for just a half a minute, and then gently rejoin the analysis. 3. Next, use a hexaflex worksheet to examine your experience, looking through the lens of the hexaflex. All components of the hexaflex emerge in this exercise. See if you can characterize your own comings and goings in each dimension. a. Present moment: Note the number of times you found yourself out of touch with your partner—off in your head. What were you doing while you were gone? What did you notice when you returned? What happened in your relationship to your partner when you were truly present and when you were gone? b. Acceptance: When you were gone, what were you doing? Were you trying to get it right? What was unacceptable that you were working on? Were you rebelling against the instructions? Were you generating alternative (and improved) ways of doing the exercise? Thinking that you picked the wrong sweet spot? Comparing yours to the other person’s? Notice your own discomforts and the effort you put into them in this simple, sweet, short exercise. c. Defusion: Take a moment and note the stories you told yourself during the exercise and the ways that they captured your attention during the exercise. d. Self: Notice the ebb and flow of you-as-content and the you that was just there, present, appreciating, and appreciated. Note the you who showed up when you let go of stories, struggles, doing it right, comparing, and evaluating.

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e. Values: There are implicit values present in this exercise. First, there’s the value you’re pursuing that put you in this exercise. You’re not here by accident. I assume that you value entering more significant present-moment-focused conversations with your clients. In a more general sense, note that there is another human sitting across from you in this exercise and that you value being there for that person. Take a moment and notice the ways these values were lived in the short minutes of this exercise. f. Commitment: If you noticed that you went away in the exercise, note also that you returned. Why did you return? It was not merely to follow instructions. Notice what it meant to you to come back. Notice what those moments of appreciation and being appreciated meant to you. Was it not the case that each of your own gentle returns was a lived example of committed action? What would it mean to you to practice that gentle return and to bring that return into the room with your most troubled clients? You’ll find a version of this exercise that can be done with individual clients on the DVD-ROM. That variation involves you leading the exercise and taking on the role of the appreciator. In that version, you can also coach slowing down of the client and you yourself can express appreciation for what the client has expressed. The exercise is useful in your supervision group, but it can also be done in group therapy with only minor revisions. As is done in individual therapy, the therapist should lead the exercise and coach all of the participants to slow down, pause, linger, and return to the task. An additional variation that can be used both with clients and with your consulting group is to do the exact exercise format with different content. The same exercise can be done as the Sad Spot, the Excitement Spot, or the Fear Spot, for example. Joanne Steinwachs, a friend in Denver, has led an entire therapy group in which they did Â�variations of the exercise each week of the group. For the purposes of this book and this chapter, the exercise prepares us to examine all areas of functioning on the hexaflex, to practice mindful use of the hexaflex worksheets, and, importantly, to cultivate our skill at making the gentle return back to our clients and perhaps more broadly to our own lives.

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THE CLIENT DESCENDING EXERCISE The next exercise imposes the same restrictions and the same roles. As difficult as remaining present is with sweet content, the challenge with difficult content is much greater. This exercise brings us a bit closer to what we face in the therapy room. The restrictions are still in place because they will allow us to watch very directly, unobscured by our busy activity as therapists, the kinds of reactions we have in therapy. This exercise calls us to sit in the presence of pain, both our own and that of our partner in the exercise—or, if we are witnesses, to both. In this exercise I ask therapists to think of a specific client for whom they have a concern. Participants may also select a person who isn’t a client for whom they carry a concern. I’ve even had people do the exercise using themselves as the subject of the exercise. Using a difficult client, however, is the standard. Prior to the exercise, I inform the participants that I’m going to ask them to watch the client descend to the depths over a long time period. I’ll ask them to watch the descent and imagine that they’re completely incapable of stopping that descent. I ask them to stop just short of the client’s death. Perhaps there are things worse than death, like standing on the edge of it until the last day of life with no respite. The exercise is hard, and therapists shouldn’t do this for no reason. We do it because when we’re in the presence of such pain, we’re extremely prone to work at making the pain stop. As described throughout the book, behavior under aversive control tends to be less flexible and less sensitive to aspects of context other than the aversive. Under such conditions, working with our most difficult clients, we need maximal sensitivity in order to see small shifts in their responding and in our own. The exercise doesn’t ask participants to accept the fact of a client’s descent, only the experience of it in the exercise. The exercise allows us to practice acceptance and mindfulness in the presence of extraordinary pain. If we can cultivate such mindfulness, we’re more likely to better serve our clients. The exercise will also provide many more opportunities to watch clinically relevant ACT processes that will certainly emerge in session. As in the Sweet Spot Exercise, the person who isn’t speaking has the job not to intervene. In some ways, this is difficult, because all of your clinical repertoires will come to the fore. In some ways, it’s simpler than working because it frees you to just be a witness to your partner and to your own processes.

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The Client Descending Exercise Structure This exercise has precisely the same structure as the Sweet Spot; the only difference between the two is the introduction to the exercise and the content of the mindfulness exercise. Apart from this, the restrictions on speaker and listener and in regard to turn taking are identical to those in the Sweet Spot Exercise. If you’re leading this exercise, you should read the exercise slowly, mindfully, and gently. Listen to your own words one by one. Pause regularly and let your own words settle around you. It will help you catch up with yourself. It will help you to set the pace for the exercise.

The Client Descending Exercise Script Just allow yourself to settle into your chair and breathe. See if you can begin by letting your attention come to all the activities that brought you here this morning. I’d like you, as if you could watch it in a movie, to watch yourself get up this morning, preparing yourself to leave. And maybe you would notice some busyness that you had, thinking about what was coming. So just breathe and take a moment and let yourself notice that sort of buzz of activity—as if you could feel it in your own skin, a sort of physical buzz—all of that movement and activity in parts of your body. And breathe. Just notice where you feel that in your body, and then begin to let your attention follow you through your activities that brought you here. Let yourself notice little places along the way: as you found your way to the building and up into the room, taking little stops along the way to notice the things that you saw. And the preparation to get yourself seated in these chairs. And settling in and preparing to do this piece of work. See if you can notice any nervousness or anticipation. And let yourself just breathe that in and out, and see if you can locate where you feel that in your body. And allow your breath to just permeate that sensation, to just flow through it. Begin to notice what it’s like to sit right here in this very chair, at this very moment. And breathe gently, gently. Let your awareness come to rest on your breath. Take just a moment to notice the tiny sensations that come with the inflow and outflow of each breath. See if you can notice tiny differences in sensation between the inflow (cool) and the outflow (warm.) Just take a moment to appreciate your own breath, that through all those activities this morning, your own breath was there, waiting for you. And let each breath invite you into this very moment. 211

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Let each breath invite you to notice your own body, your own person, sitting right here, right now. And if you find yourself getting ahead, just gently, gently come back to the sound of my voice. Let your breath invite you back into this moment. And then follow the next instruction that I ask of you. And breathe. And I’d like you to imagine now that, in front of you, there’s a file cabinet. Before you reach for it or open it, I would ask that you call to mind a client who you’ve worried about, a client who maybe you’ve wondered whether you could help—perhaps a client that you go home on weekends and you wonder, is this one more weekend he spends in isolation? Will you even see him the next week? Will he give up? Will he give up on you? On himself? And just let yourself breathe then in and out for a moment. And I’d like you to let that file cabinet before you fill with photographs of that client. And I’d like you to imagine that you reach out so that your hand just barely touches the handle of that file drawer. And let yourself feel your fingertips, as if they were just barely touching the drawer. And breathe. And let yourself know what is in that drawer. And gently, gently draw the drawer open, and allow yourself to hear the sound of that drawer slide open. And breathe. And imagine that you could reach in, toward the front of the drawer, and place your fingertips on a photograph. I’ll ask you to imagine that you draw that photograph out of the file drawer. Listen to the sound of it as you draw it out. And then allow it to come to rest in your lap. And let your eyes begin to move across that image. And I’ll ask you to let yourself see, to let an image form there of your client as he is right now. It could be a picture of him somewhere in his life or in your office. And let yourself see, in that picture, the way that client holds his body. Is there tension in his body? Does he look closed off? Or does he in some way look as if people might walk by him and not even notice the sort of suffering that he has? But I’ll ask that you let yourself see that. So let your eyes linger on that client’s face and see if you can see in that face, in those eyes, that person. And see that struggle that others may not see but that you know about. And just take a moment and let yourself breathe that struggle in and out. You can hear the echoes of it, maybe, from the sessions you’ve had. He’s begged you for answers. And see if you can see that longing in that face. What is it that he hopes for in his life, if he were capable of hoping? What does he long for? Can you let yourself see that? And I want you to begin to notice how much you want to be able to reach in there and help him, to reach in and make a difference for him. And let yourself just breathe your own longing in and out like air. And I’ll ask you, beg you, to let it be so that no matter what you do, no matter how hard you try, that helping him is beyond your grasp. Like someone falling down the stairs 212

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who’s just out of reach. Where you reach out toward him to stop that tumble, but you can’t quite reach far enough. As if, when he begins to fall, you can see that look in his eyes reaching out toward you and knowing that there’s no reach quite far enough. Just linger at that cusp right there. Let yourself look into those eyes that have that longing. Don’t turn away. Just let yourself rest there for a moment and breathe that longing—his longing and your longing—in and out. And breathe. And take one last look at that face, and allow that picture to be lifted from your lap. And one last look. And let it drop gently, gently into the drawer. And then I want you to just rest a moment and let what you just saw gather up around you. Let yourself breathe in and out your own powerlessness. Maybe your own insecurities about whether you could make a difference. And then I’ll ask you to reach in again, and I’ll ask that you pull a photo out that is ten years from this day. And if you’re afraid this client is going to die, I want you to let him still be alive. So, if he’s someone who wants to die now, let it be that that wanting to die just stretches out for ten more years, and he carries that weight. And draw that photograph of him out of the file drawer, and let yourself see in that photo, as you carry it gently to your lap, what that face looks like after ten more years of paying that cost. No one wants to look at him, but would you? Let me invite you to just breathe him in and out. Let yourself see what ten more years looks like written on that face. Linger on those eyes for a moment. Let your awareness stretch out into his life and see all the costs that he’s paid over those ten years. Are his children lost to him? Partners? How many nights and days has he spent alone? Let yourself see in those eyes that person who hoped something could be different but maybe knew that it would go just like this. Let yourself imagine it was as if you could reach out toward him, to stop that tumble, but no matter how far you reached, no matter how hard you tried, you couldn’t prevent that tumble down. And breathe gently. And if you notice yourself wanting to turn away, just gently turn back and let yourself look into those eyes and see those costs written in his eyes. And breathe. And I would like you to just imagine now that you take one last look at that image and let it slip gently. See if you can notice that you almost don’t want to let him go. But I’ll ask that you do let him go and let him slip, slip back into the file drawer. And let yourself feel the weight of those ten years of costs. And breathe. And now I’m going to ask you to reach far, far back into the file cabinet. And I’m going to ask you to pull a photograph from the back of that cabinet that shows that client on the very last day of his life, in his last hour. Let yourself draw that photo gently up, and bring it to your lap, and cradle it there. See 213

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if you can hold that photo as if it were on the most fragile sort of paper. And let yourself look down into that face that has known a lifetime of costs. Let yourself see that person as he takes that last hour to look back over his own life at the things he had hoped for. There it is in his face. How many days has he paid that price? See if you can remember back to when you had hoped to reach in there, how much you had wanted to make a difference for him. And let it be so that no matter what you did, no matter what you said, that he slipped away and found himself on that last day. How empty is that life? How painful? And how it is written in those eyes? And I’ll ask that you honor him by being present in his last hour. Just let that last hour saturate you, so that when he passes, someone will have known. Someone will have known, someone will have cared to know. Would you be his witness so that when he passes, someone knows? And breathe, breathe. And as you breathe, just see if it’s possible for you to say yes to that suffering. To just allow it to be there and, for just a moment, to let go of the struggle with that. To just let it saturate you. And now I’ll ask you to take that photo, and with the most gentleness you can bring to it, take one last look at it, let yourself look one last time in those eyes so that someone saw them, and let it slip gently, gently back into the drawer. And place your hand on that drawer, and let yourself notice that sound as the drawer goes gently closed and comes to a stop. And I’ll ask that you take a moment to just breathe in and out what you saw. See if you can let go of any struggle with that for a moment. I’m going to ask you in a moment to open your eyes, and when I do, I’m going to ask that you listen to my coaching. And what I would like you to do is this: don’t explain the concern you have but let it be expressed as gentle as water being poured from a jar. So if you find yourself trying to get it right or make sure the other person understands, I want you to honor that person you witnessed by just gently coming back to giving expression to that concern that you carry and to that decline that you saw. Let yourself be the voice for that. I’m going to give you just a moment to linger and be saturated by what you witnessed. And in a moment, I’m going to let you open your eyes.

Debriefing the Client Descending Use the same debriefing structure for the Client Descending as was used for the Sweet Spot Exercise.

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EXPERIENTIAL ROLE PLAY EXERCISE WITH CASE CONCEPTUALIZATION The last of the exercises—the Experiential Role Play—begins with the Client Descending Exercise. Instead of expressing and appreciating the concern for the client, the pair moves immediately from the Client Descending Exercise into a role play. At the end of the exercise, just after participants see the client on the last day of his life, I ask the participants to imagine placing that photo back into the file drawer and then imagine seeing the client in a therapy session the next week. Therapists are asked to imagine that their awareness is poured into the skin of her client. When the pair opens their eyes, the person who has been designated to go first plays her own client. Again, the details of the exercise are in the script below. In addition, a version of this exercise can be found on the disc that accompanies the book.

Experiential Role Play with Case Conceptualization Structure The following role play should come after having done the Client Descending Exercise. 1. Have participants provide a thumbnail description of the client and decide who will be the client and who will be the therapist in the first round of the role play. 2. Reestablish the focused mind-set you fostered during the Client Descending Exercise. 3. Instruct the participants to imagine themselves poured into the skin of their client. 4. Instruct participants that when they role play therapists, to bring the same mindful presence to bear in the clinical conversation. Warn them that this is more challenging when the therapist gets to talk. Advise them that you will create mindful pauses in the instruction, but that they should also take them spontaneously.

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5. Instruct the participant playing the therapist to intervene with the participant who’s playing the client. 6. Stop the therapist and client after a couple minutes. Have them rest in silence for a few moments, notice the busyness of their minds, and pause again, then come even more gently back to the task. 7. Stop the therapist and client again and have both allow their eyes to close. Take about two minutes during which the person who was the client sits in silence and notices the qualities of that experience. 8. Have the therapist and client switch roles. Participants playing the therapist should be instructed to pour their awareness into the skin of their own client. 9. Repeat the role play as above. 10. Debrief using the debriefing instructions that follow the Sweet Spot Exercise. 11. Make a case conceptualization using the hexaflex worksheets and rating scales. Add variations: a. The simplest variation is this: After the role play has been going on for a while, have the therapist and client switch roles. By the time the role play has gone on for ten or fifteen minutes, the person who has been playing the therapist will have a good feel for the client and should be able to play the client reasonably well. This casts the actual therapist for this client back into the role of the therapist again. This shift in perspective can considerably enhance your flexibility as a therapist, will cause you to see your client in a different light, and will alter your relationship with your client. b. If you have witnesses, rotate all roles clockwise. Let the witnesses take on the roles of therapist and client. As in the first variation above, shifting to the observer role enhances flexibility. It allows you to see yourself and the client through different eyes.

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Experiential Role Play Exercise Script Just let your eyes gently close. I want you to just take a moment and let your attention gently come to rest right now on the inflow and outflow of your breath. And if you find yourself thinking forward to the exercise, gently let go of that and notice again that in the midst of all that mental activity, your breath continues. And no matter how busy you get, it flows like a river. It requires nothing of you. Just let yourself linger for a moment inside that steady stream of inflow and outflow of breath. Each time you find yourself drifting away in thought, into the future or past, just let that steady inflow and outflow draw your attention gently back. Allow yourself to just notice all of the tiny sensations—in your lips, your mouth, the gentle rise and fall of your own breath—each time you drift, gently returning back to your own breath. And if you find yourself irritated, wanting to move along, just notice that—that push—and imagine that you just gently release that and come back to this very next breath…and this breath. Now I want to invite you to imagine that file cabinet before you—and remember, as you gaze at that cabinet, those photos you looked at previously. Just let the weight of that rest on you. See if you can let yourself recall the ways you struggled with that, and before you open the cabinet, take a minute to breathe those struggles in and out. I’ll ask you to reach forward and let your fingertips come gently to rest on the handle of that file cabinet. Imagine that you slowly and gently draw the file cabinet open. Let your hand rest on the files, and let yourself know the costs that are written on the photos. Let yourself find, in that cabinet, a photo of your client on the very last day of her life. Gently draw the photo out. Maybe imagine the paper is fragile, that you have to take it out with care and gentleness. Bring it to rest in your lap, and see if you can hold it like some sad but treasured thing. Just notice the feel of it as you cradle it and breathe. Let your eyes begin to see that client on the last day of her life. See if you can let yourself notice the tiniest details in her face as she sits on that last day. See if you can let yourself see, in those eyes, all of those costs that she has paid. Let yourself see in her face someone who can look out across the years and know all the costs that have been paid. See if you can see in that face someone who once hoped for more or somebody who couldn’t take it home. Let yourself notice that you can only be a witness to this; there’s no way you can reach in and stop it. And breathe. Let it be as if the cost this person paid can be breathed in and out like air, so that as you witness her, you become saturated with those costs. And breathe. Now I want you to imagine that you take one last look into the face of that client, and let yourself know what it would have meant to you to have 217

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been an instrument to her, to make a difference to her. See if you can let yourself feel sorry for that. Then gently, gently let that client’s photo slip back into the file cabinet, and just linger for a moment with your hand on top of those photos, breathing—and gently let the drawer slide closed, listening to the sounds as it slides closed. Now imagine that you’re in the therapy room, and that it is some time in the next week, and that this client is sitting across from you, as she is right now. If it’s a client you don’t see anymore, let it be as though she has returned. Picture her forming up in the chair across form you. Observe how she holds herself, how she shapes her body as she sits in the chair—and breathe. Let your eyes come to rest on her face. Is she turned away from you, toward you? What is the look on her face? Does she look sad, happy, angry, or bored? Just let yourself notice the details of her face: the way the hair lies on her face, her eyes, her breathing. See if you can look into that face and recall that person on the last day of her life, and see if you can see those costs in that face—the price that will be paid. If you looked into that face, you could see her own fear of the course her life will follow. Notice your longing to make a difference, to reach out to her. Take a moment of silence. Just be a witness to this client and her struggle. Just gently be a witness to that, as if you were watching a painting or a sunset. Now imagine that your awareness is like a liquid, and you can be poured into the client. Your awareness is like water, and you begin to become aware from the inside of what she feels like. Let that awareness gently fill her body and being—to feel that the way she shapes her body shapes your awareness. Feel it pull and twist at you so that the shape of that client’s body, the way she holds herself, starts to shape you. Let that awareness fill you and fill you, so that you start to feel from within her skin what it’s like to sit in that room. Let it fill you and fill you right to the top of your head. See what it’s like to be sitting across from that therapist. What is it like to be sitting across from him? How do you feel toward that therapist? Will he help you? Will he hear you? Can he possibly know what it’s like for you? Let yourself breathe that therapy room in and out with your client’s breath. Let yourself breathe the air she breathes. [Pause.] Let the words drop away, let your eyes close for just a moment. See if you can just feel the quality of the interaction so far. Notice the pitch and pace. If you’re the therapist, notice what’s tugging and pulling at you. Are you trying to get it right? See if you can get a feel for the way the client feels, for what words she’s using—almost as if you can hear a faint song in the background. If you’re a witness, see if you can let yourself notice the client and the therapist, the qualities of their interaction. Like a naturalist, stop, watch, and listen. Therapists, if you’re working hard, just let go of that. If you’re the client, see 218

Making Experiential Contact with Mindfulness

if you can feel what it’s like to be that person. Be true to the client. Fight for her experience in the therapy room. Breathe. When you’re ready, let your eyes reopen and rejoin the therapeutic interaction. Give yourself a chance to meet that client; give the client a chance to be met. And once again, let yourself pause. Let the words drop away and let your gaze fall to the floor. Just let all of that experience sort of gather around you, as if your awareness could come to light on one aspect of the experience and then another. Without doing anything with it, notice anything you want to do something with. Let this go and just be a witness to that experience. Let all those pushes and pulls be more of that air you can breathe in and out. And once again, I want you to just gently come back to the interaction. Pause for just a moment. When you’re ready, let yourself come gently back to the interaction.

Debriefing: Client Once more, let the words drop away. Take a moment or two in the next section of the work. To the client, see if you can give expression to what it’s like to sit inside the skin of the client. Don’t be nice. What did you see, what did you hear, what did you feel? Where were the places you felt joined or not joined? Avoid analysis and stay very close to experience. What was the experience, how did it move, what were the contours as you moved through it? Stay with the experience. Pause for just a second and consider what the client might hope for in the room.

Debriefing: Therapist Stay close to experience. What was it like to sit in the room with the client? What were the ebb and flow and contour of that experience? Again, avoid analysis.

Debriefing: Witnesses Now the people who witnessed the exchange, what was it like to watch the client-therapist interaction? Again, no analysis. Stay with experience. How did the interaction tug at you as a witness? 219

Mindfulness for Two

Finishing Up Let the words drop away. Take a moment, breathe, and let yourself be saturated by all of the different experiences in the interaction: the experiences of the client, the therapist, and the witnesses. Pause and just appreciate the complexity, the richness of those experiences. See if, for just a moment, your awareness can just gently release those experiences. Let your awareness come to rest on your own breath. Notice how your thoughts and experiences clamor for your attention. Return to your own breathing, to that same gentle inflow and outflow of breath. See if you can notice that, through all of these interactions, there remained that gentle inflow and outflow of breath, requiring nothing of you and yet sustaining you. Kindly give your own breath a moment of appreciation—a simple thing that sustains you even when you don’t have time for it.

Debriefing the Experiential Role Play We humans are really attracted to facets of the hexaflex that we really have nailed, and we spend less time on those facets we don’t know so well. Go back into the therapeutic relationship and look for those facets that you don’t have a good sense of. See if you can structure your questions like “What line of inquiry can take me into the facets of the hexaflex that I don’t see evidence for?” How much permission do we have as therapists to press clients, to move where the clients want to take us? How do we get permission to move forward? How do we check in with clients to see what they’re willing to take up? Can you say, “It matters to me what your experience here is, and I feel like we’re up against something hard.” Can you find a way to really honor their answers whether they say yes or no? What are the challenges to observing the role plays? What’s sweet in your client’s life? If you don’t think there’s sweetness in your client’s life, what could be sweet? Do you know what might be sweet in his life? Can you appreciate what this sweetness might be in her life? Can you let the client show you either what is sweet or what he might long for?

Reinduction Let your eyes gently close. Just let your attention come gently to rest on your own inflow and outflow of breath. See if you can notice how steadfast 220

Making Experiential Contact with Mindfulness

your breath is, how reliable. And if you find yourself becoming distracted, just see if you can notice those distractions, maybe give them a nod—you can come back to them later. But for now, let your attention gently, gently come back to your own breathing. See if you can begin to notice the tiny sensations that can be found in the inflow and outflow of each breath. It needn’t be forceful, but when you find your mind wandering, gently carry it back to your breath. And now imagine once again that photograph of your client and hold it in your lap. Let yourself recollect; let yourself see that face. And breathe. Just let your eyes linger on that face for a moment, breathing in and out. And then let that photo dissolve, dissolve, breathing. And let yourself begin to see that client of yours as she is right now. See if the exercises you’ve done will let you see just a little more deeply into the suffering of that person. Let yourself soften to that suffering, let yourself be penetrated by it. Notice how she holds her body, how she holds her life; feel that tension and that narrowness that constrains her. Breathe. And once more, imagine that your awareness can become a liquid that is poured into the skin of your client. With kindness, gently pour your awareness into your client. Let yourself begin to feel that trap that your client feels herself to be in. As your awareness fills your client up, let the way she holds her body begin to shape yours. Let the trap that she finds herself in grab hold of your awareness and squeeze it. Let yourself wonder, “Will my therapist see me? Can anyone understand me? Know me?” Just let yourself breathe that struggle in and out. When you’re ready, open your eyes as the eyes of your client. Be true to her. Be her voice in this room. Respect her by being true to her. When you’re ready, rejoin the conversation—the same session, the next session. Go ahead and rejoin that conversation. [Pause.] Let the words drop away. Let yourself go silent. You can continue to go along this path, but stop for just a moment to rest. See if you can bring your awareness to your own pace. Is there urgency to it? Are you hurrying? Just let it well up around you—and breathe. When you’re ready, I want you to come back to the interaction and see if you can really bring intention and awareness to your pacing. See if you can find a pace where you are right there with your client. Just take a moment, take a few breaths, and notice the gentle inflow of breath. Witnesses, see if you can just practice bringing attention to one or the other side of the interaction. Breathe. And when you’re ready, just let it be as if you stood back up on that same trail and then took your time moving back in the way you’ve been going. [Pause.]

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One more time let the words drop away, and let your eyes gently close. Notice what it’s like to be that therapist, that client. If you’re observing, have a heart for both the client and the therapist. Therapist, you have the flavor of your client now. Imagine that your awareness could be poured into that body across from you. Imagine that your awareness can be poured like water into the skin of the person across from you. Let yourself take on the feel, the posture of that client. [Participants reverse roles.] Imagine yourself being poured across that transaction. When you open your eyes, be yourself, the therapist, looking across at your client. If you were the therapist, feel what it’s like to be the client. Was that person hearing you at all? When you open your eyes, rejoin the work—except with the roles of therapist and client reversed. [Pause.] What is it like to sit in that aware place as a client and as a therapist? Consider this question: If you weren’t in the room with that client, trying to say the right thing, what would you like to say to her? Take a minute. Let your attention come to rest on your own breath, and then gently, gently come back to the interaction. [Pause.] One last time, let the words gently drop away. You’re not done. There is no done. Let the whole experience gather around you. What was it like— client, therapist, witnesses? Draw your attention to your own breathing. There it is, waiting for you. If you find your mind wandering, let it come to rest on your own breath. Notice the way the mind wants to pull you this way and that, to get on to the next thing. Notice then that your breath is there, waiting for your return. Just take a moment to appreciate that sweet simple thing: your own breath moving in and out of your body. This very breath. And now open your eyes and take a few minutes here to stay close to the experience. What kinds of things did you notice? Not analysis, but what was the experience like? What was the transition like? If you were observing, what did you see?

Debriefing the Experiential Role Play and Mindful Case Conceptualization All of the debriefing instructions described for the Sweet Spot and the Client Descending should be applied to this exercise. The exercise

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provides a very rich set of interactions. Linger over them. Your inclination is likely to be to absolutely launch into case conceptualization. Notice that eagerness to move to the conceptual. Cause your little group to pause until you can sit with the urgency. You can do this, but it will require you to bring your careful attention to bear on the task in a way that is very, very different from our usual shift into the conceptual. In addition to the debriefing suggested in the previous exercises, consider adding these small additional instructions: 1. Designate someone in your group to ring the bell, as it were, to call the small group to a mindful moment during the case conceptualization. Encourage anyone in the group to request such a moment if they feel the process is racing away. It will be good practice for the group to respect the process for others and to notice their own drive to action. 2. Have everyone in your small group bring their hexaflex worksheets into their lap and let their eyes travel across the sheets. Remain silent and allow your eyes to travel across the sheet without writing anything. If you begin to think of things to write, gently let those go, and look around at your little group and let yourself soak in the magnitude of the human task we have all adopted. 3. â•›Case conceptualization of the therapist: Work through a case conceptualization of the therapist (as described in chapter 7). Be sure to walk all the way around the hexaflex. Take some mindful moments in this process. Just stop. Please. 4. â•›Case conceptualization of the client: Work through a case conceptualization of the client (as described in chapter 7). Be sure to walk all the way around the hexaflex. Take some mindful moments in this process. Just stop. Please. We have time enough.

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Epilogue

Slowing Down

One of the central arguments of this book, and I think of ACT generally, is that all of us—whether client or therapist—experience similar problems in living. These problems vary from each to each in degree but not in kind. This egalitarianism of dysfunction, of course, extends to authors too. So now it’s my turn to wander from the present moment and worry about the unknowable future. How will this book be received? This book was born from science, but I didn’t write it primarily for scientists. There are a thousand places in the preceding pages where I might have unpacked the empirical and theoretical justification for my assertions. Had I done that, though, most clinicians would have stopped reading before finishing the first chapter. I believe there is relevant empirical evidence, theory, or both for the work I’ve described herein. I have spent a lot of time in other contexts making the scientific argument for all I’ve claimed in these pages, and I’ll continue to do so. But setting forth an exhaustive, scientific account of the whys and wherefores of mindfulness for two wasn’t the purpose of this book. Instead, I wanted to offer you something in the way of a very practical experience that could shape the conversations you have with your clients. Because I took for granted a number of theoretical and empirical matters, I know I’ll draw criticism for this book. Some scientists will cluck their tongues. I can live with that. I never intended this to be an endpoint of a scientific analysis. Rather my vision was for it to be part of an iterative process that moves between the clinic and the lab, between

Mindfulness for Two

basic and applied theory, between the highly theoretical and the wholly practical. My hope was to speak to clinicians, and, to a somewhat lesser extent, to set an empirical agenda for scientists who can see both the science from which this work comes and the human need it seeks to fulfill. We have time enough to sort these matters out, though it often doesn’t seem so. Our savanna minds didn’t keep us alive by idling away the hours. But you took time for this odd book. Perhaps you were looking for a significant, hard-to-define something more in your own work. It’s my hope that taking this time will help you to make time for yourself and for the people you serve. What would it mean if we slowed just a bit? What would it mean to stop long enough to recognize our own face in the mirror one morning? What would it mean to look deeply into those eyes? What does that person we see there need? Do we have time to recognize that person? To listen? To hear our own hearts? What small gift could you make to yourself this day? What kindness would you offer? This book is a small gift I’ve offered to myself. It’s a place where I’ve let the years that have welled up around me spill out. I’ve attempted to give voice to the influences of hundreds of teachers, clients, students, and friends of this work worldwide. This book is a place where I’ve allowed myself to speak in my own voice. I hope that all of you who have contributed will hear a bit of your voice echoed in mine. I hope that those of you who are just now joining me will find things in these pages that serve both you and the clients you serve. We’ll need to slow down in order to really answer these questions. Kindness is a simple thing. And sometimes a return to simple things can help us. At times we feel the need to go back to plain things. To stones, earth, grass, wind. To things we have known a long time, to what we knew when what filled the hours was dirt and a few sticks, a pile of leaves or some thin, white bones from a long-dead bird. The huge rock near the creek was not too hard to lie on then

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and the sun on bare skin felt warm. We did not feel the press of time as we do now. The world seemed firm and real, and life was slow, and long, and good. —Carolyn Elkins, “What We Knew” (2002, 23)

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Appendix A

Using the Mindfulness for Two DVD-ROM

Bound into the back of this book, you’ll find a DVD-ROM with all sorts of interesting things you can use to support your experience with the book. Although the disc contains video, it isn’t a DVD that you can play in your DVD player and watch on your television set. In order to use the disc, you’ll need a personal computer.

VIDEO There are seven video segments on the disc. You can see the Sweet Spot and Client Descending exercises, and you can practice case conceptualization on the six remaining experiential role plays. In particular, I offer a case conceptualization of “Emily and Kate: Session 2” in chapter 7. The worksheets with my notes appear on the disc as “Emily and Kate 2 HDFEI.pdf.” These segments were filmed in Denver, Colorado, in April 2008. The individuals who appear in these videos as clients adopted invented clinical personae for illustrative purposes, but I would resist calling what you see in these segments acting. While the “clients” assumed some details that would lend structure to the interviews, I think you’ll agree, after you watch the videos, that something essentially human and undeniably real emerges. All of the participants, therapists and “clients” alike,

Mindfulness for Two

had recently completed a three-day training with me on the material featured in this book. Though the personae they adopt for the videos are invented, with their permission we used the real names of the participants to identify them in these segments. In order to view these videos, you need to use QuickTime player, which is available free of charge for both the Windows and Apple platforms at www.apple.com. The segments are named according to the individuals they feature:

• Emily and Kate: Session 1 (Sweet Spot Exercise) • Ellen and Matt (Client Descending Exercise) • Ragnar and Brandon (an experiential role play) • Emily and Kate: Session 2 (an experiential role play) • Bennett and Cari (an experiential role play) • Joanne and Lisa (an experiential role play) • Kelly and Cari (an experiential role play) AUDIO You’ll find three audio clips in MP3 format that include my voice doing real-time inductions to the three mindfulness exercises in chapter 8: Sweet Spot, the Client Descending, and the Experiential Role Play. Depending on how your system is configured, you should be able to move these files into any major audio software and, from there, onto a portable music player or a CD for playback.

PDF WORKSHEETS AND DOCUMENTS The worksheets and figures in the book also appear on the disc in PDF format. Feel free to print them and use them as you please in your clinical and educational work. To view and print these documents, you’ll need either Adobe Acrobat or Adobe Reader. Adobe Reader is available free of charge at www.adobe.com.

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Appendix B

The Valued Living Questionnaire (Version 1)

The Valued Living Questionnaire that appears in chapter 7 was refined from an earlier version especially for use with the HFDEI as it’s presented in this volume. The original version has been used in a variety of research projects and may be of interest for some researchers and practitioners. It is reproduced below, and there is a reproducible PDF version available on the DVD-ROM.

Mindfulness for Two

Valued Living Questionnaire Below are areas of life that are valued by some people. We are concerned with your quality of life in each of these areas. One aspect of quality of life involves the importance one puts on different areas of living. Rate the importance of each area (by circling a number) on a scale of 1 to 10. 1 means that area is not at all important. 10 means that area is very important. Not everyone will value all of these areas, or value all areas the same. Rate each area according to your own personal sense of importance. Area

not at all important

1. Family (other than marriage or parenting)

1 2 3 4 5 6 7 8 9 10

2. Marriage/couples/ intimate relations

1 2 3 4 5 6 7 8 9 10

3. Parenting

1 2 3 4 5 6 7 8 9 10

4. Friends/social life

1 2 3 4 5 6 7 8 9 10

5. Work

1 2 3 4 5 6 7 8 9 10

6. Education/training

1 2 3 4 5 6 7 8 9 10

7. Recreation/fun

1 2 3 4 5 6 7 8 9 10

8. Spirituality

1 2 3 4 5 6 7 8 9 10

9. Citizenship/community life

1 2 3 4 5 6 7 8 9 10

10. Physical self-care (diet, exercise, sleep)

1 2 3 4 5 6 7 8 9 10

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extremely important

The Valued Living Questionnaire

In this section, we would like you to give a rating of how consistent your actions have been with each of your values. We are not asking about your ideal in each area. We are also not asking what others think of you. Everyone does better in some areas than others. People also do better at some times than at others. We want to know how you think you have been doing during the past week. Rate each area (by circling a number) on a scale of 1 to 10. 1 means that your actions have been completely inconsistent with your value. 10 means that your actions have been completely consistent with your value. During the past week Area

not at all consistent my value

completely consistent with my value

1. Family (other than marriage or parenting)

1

2

3

4

5

6

7

8

9

10

2. Marriage/couples/ intimate relations

1

2

3

4

5

6

7

8

9

10

3. Parenting

1

2

3

4

5

6

7

8

9

10

4. Friends/social life

1

2

3

4

5

6

7

8

9

10

5. Work

1

2

3

4

5

6

7

8

9

10

6. Education/training

1

2

3

4

5

6

7

8

9

10

7. Recreation/fun

1

2

3

4

5

6

7

8

9

10

8. Spirituality

1

2

3

4

5

6

7

8

9

10

9. Citizenship/community life

1

2

3

4

5

6

7

8

9

10

10. Physical self-care (diet, exercise, sleep)

1

2

3

4

5

6

7

8

9

10

233

Recommended Reading

What a dangerous section to include! This alone could take up the entire page count. I’d better keep it brief.

ON ACT ACT literature for clinicians is growing fast. To date, much of it has been published by New Harbinger, whose website is a good place to look for other book and video titles: www.newharbinger.com. New Harbinger also publishes a range of client-focused ACT books that can be used for self-help or integrated into therapy, most notably Get Out of Your Mind and Into Your Life, by Steve Hayes with Spencer Smith. The major book that develops the theoretical foundations of ACT is Acceptance and Commitment Therapy, by Steve Hayes, Kirk Strosahl, and Kelly Wilson (Guilford Press, 1999). This title is currently under revision; the new edition will be available from Guilford in 2009. Arguably the other foundational title for ACT is Relational Frame Theory: A PostSkinnerian Account of Human Language and Cognition, by Steve Hayes, Dermott Barnes-Holmes, and Bryan Roche (Springer, 2001). While dense and technical, these books offer unparalleled access to the �theoretical mechanics that make ACT what it is.

Mindfulness for Two

ON MINDFULNESS There are quite simply too many books on the subject of mindfulness, both within and without the great spiritual traditions, for me to mention. To recommend some may seem to slight others through negligence, which surely wouldn’t be my intention. I have tremendous respect and affection for Jon Kabat-Zinn and believe that his books are required reading for those interested in a clinical application of simple, conscious awareness to the present moment. In this area, however, I recommend that you let your curiosity be your guide. I would also recommend the reader look at the work of Mark Williams, Zindel Segal, and John Teasdale on mindfulness-Â�based cognitive therapy (MBCT). Though these books all come at the work from a very different perspective, we are certainly fellow travelers.

OTHER BEAUTIFUL BOOKS REFERRED TO IN THIS TEXT, AND UNMENTIONED BUT IMPORTANT INFLUENCES Victor Frankl’s Man’s Search for Meaning, in case you hadn’t gathered as much, has meant a very great deal to me. A number of editions are in print, notably from Beacon Press. Carl Rogers’s On Becoming a Person seems essential. The poems of T. S. Eliot are good for lifetimes of reflection. His collected poems and plays are available in a nice hardcover from Harcourt (1952). Also, in the realm of poetry, I recommend Carolyn Elkins’s Daedalus Rising from Emerys (2002). The reference I made to Camus’ “An Absurd Reasoning” can be further explored in The Myth of Sisyphus and Other Essays, which is available from Vintage International in the 1991 edition. My relationship with Camus’ essays is long and deep. I got my first copy of the essays thirty-eight years ago from my brother Randy. My love for these essays has only grown since that time. I referred to Sebastian Moore’s Let This Mind Be in You: The Quest for Identity Through Oedipus to Christ (Winston Press, 1985), which is a wonderful book. Moore is a bit psychodynamic for my taste, but the sensitivities are exquisite. Also in the area of spiritual writing, though I didn’t reference it specifically in the book, I’m very taken with Dao De Jing: A Philosophical Translation, by Roger Ames, David Hall, and Lao Zi

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Recommended Reading

(Ballantine, 2003). Ernest Kurtz and Katherine Ketcham and their book The Spirituality of Imperfection: Storytelling and the Search for Meaning (Bantam, 1993) are a principal source of my persistent interest in sitting inside significant questions. The book is nominally about spirituality in Alcoholics Anonymous, but really the stories are marvelously universal. I cannot overemphasize the importance of behavior analytic writing and thinking on the development of this work. Do yourself a favor and read what B. F. Skinner actually wrote rather than relying on secondhand reports by people who never really did their homework. I heartily recommend Skinner’s essays in volumes such as Cumulative Record, first published in 1959, or Contingencies of Reinforcement, published in 1969. Neither is still in print, though used copies can be found online. If you want to get a taste of the really odd edges of behavior analysis that captured my attention, please read some Willard Day. Sadly, Willard died fairly young and talked more than he wrote. However, my first teacher of behavior analysis, Sam Leigland, compiled a volume of Willard’s canonical papers in a volume called Radical Behaviorism, which can be purchased from New Harbinger under the Context Press imprint. With the Skinner volumes and especially with Willard’s contribution, you’ll begin to get a sense of the incredibly broad range of interests that can be found within the behavior analysis tradition. Narrow indeed!

RECOMMENDED BROWSING The Association for Contextual Behavioral Science (ACBS) is a central point for all things ACT, and it serves as a hub for the functional contextual cognitive behavioral sciences. The website, www.contextualpsychology.org, features articles and information, a calendar of training events, and the schedules of the ACT Summer Institutes and international conferences. Membership in ACBS is required to access much of the information on the site, but, in keeping with ACT’s values orientation, ACBS annual dues are values based. You set your annual dues according to how much value you place on membership. As little as $1 will get you into this exciting and supportive community.

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References

Abbot, B. B. (1985). Rats prefer signaled over unsignaled shock-free periods. Journal of Experimental Psychology: Animal Behavior Processes, 11(2), 215–223. Arnold, M. (1998). Matthew Arnold: Selected Poems. New York: Everyman. Badia, P., Harsh, J., & Abbot, B. (1979). Choosing between predictable and unpredictable shock conditions: Data and theory. Psychological Bulletin, 86(5), 1107–1131. Baumeister, R. F., Campbell, J. D., Krueger, J. I., & Vohs, K. D. (2003). Does high self-esteem cause better performance, interpersonal success, happiness, or healthier life-styles? Psychological Science in the Public Interest, 4(1), 1–44. Blake, W. (1976) Eternity. In A. Kazin (Ed.), The portable Blake (p. 135). New York: Penguin. Bond, F. W., & Bunce, D. (2000). Mediators of change in emotionfocused and problem-focused worksite stress management interventions. Journal of Occupational Health Psychology, 5(1),156–163. Bond, F. W., & Flaxman, P. E. (2006). The ability of psychological flexibility and job control to predict learning, job performance, and mental health. Journal of Organizational Behavior Management, 26(1– 2), 113–130.

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Kelly G. Wilson, Ph.D., is associate professor of psychology at the University of Mississippi. He is a central figure in acceptance and commitment therapy (ACT), and was one of the authors of the landmark Acceptance and Commitment Therapy. (Guilford Press, first edition 1999, second edition 2009). Wilson is among the most sought-after ACT trainers. His popular experiential workshops touch thousands of clinicians and students each year. www.onelifellc.com Troy DuFrene is a writer specializing in topics in psychology. He is c� oauthor of Coping with OCD (New Harbinger, 2008) and, with Kelly Wilson, of Things Might Go Terribly, Horribly Wrong (New Harbinger, 2010). DuFrene lives and works in the San Francisco Bay Area. www .troydufrene.com

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