“Trauma-Focused ACT is going to go down as one of the great

contributions to the field of trauma-informed care. Written in a

highly accessible, practical style, Harris provides the acceptance
and commitment therapy (ACT) therapist with a comprehensive,
step-by-step approach to working with traumatized clients. The
book is chock-full of tidbits of clinical advice that could only
come from a highly skilled therapist with loads of experience
working with trauma. If you read this book from cover to cover
(and maybe read it again), you will have a complete sense of how
to roll out, manage, and complete a high-potency treatment with a
traumatized client. There aren’t many books out there that achieve
this high ground, and this is one of them! Highly recommended.”
—Kirk Strosahl, PhD, cofounder of ACT, and coauthor of
Brief Interventions for Radical Change

“This beautifully written and intensely practical book offers a rich

array of clinical insights and strategies covering the many
nuances and concerns that show up when working with various
forms of trauma from an ACT point of view. I consider it the
ACT book for trauma, and a must-read for mental health
practitioners who are looking for a compassionate and
transformative approach to helping their clients heal old wounds
and engage their lives now in ways that matter to them.”
—John P. Forsyth, PhD, coauthor of The Mindfulness and
Acceptance Workbook for Anxiety and Acceptance and
Commitment Therapy for Anxiety Disorders

“Nobody writes with greater clarity and offers more concrete,

useful, and innovative suggestions and strategies than Russ
Harris. This is the definitive book for treating trauma-related
difficulties with compassion, courage, and cutting-edge scientific
tools.”
—Todd B. Kashdan, PhD, professor of psychology, and
author of Curious? and The Upside of Your Dark Side
“This book is a major milestone in understanding how ACT can
support recovery from trauma. In this comprehensive manual,
Russ Harris provides rationales, exercises, and transcripts to give
therapists clear guidance on working effectively with the full
range of problems associated with trauma. From hypervigilance,
reexperiencing, avoidance, freezing, and dissociation to responses
of shame and guilt—Trauma-Focused ACT provides numerous
sensitive, respectful, and progressive ways to work with clients.
Written with warmth and compassion, this is the indispensable
guide for using ACT to help people with trauma.”
—Eric Morris, PhD, senior lecturer and psychology clinic
director at La Trobe University, and coauthor of
Acceptance and Commitment Therapy for Psychosis
Recovery

“We’ve known for a long time that psychological flexibility skills

are very important in addressing trauma, but we’ve had a harder
time creating trauma-focused versions of ACT that can establish
those skills. This book helps fill that gap, from one of the clearest
writers and most creative practitioners in the ACT community. I
learned something new in every subsection. Highly
recommended.”
—Steven C. Hayes, PhD, Nevada Foundation Professor in
the department of psychology at the University of Nevada,
Reno; and originator of ACT

“Another gem from Russ Harris. Trauma work can be daunting—

fraught with anxiety and vulnerability on the part of the therapist.
By the end of the opening paragraph, you will feel your shoulders
relax and know you are in capable and compassionate hands. It’s
all here: from the best, most accessible description of the
polyvagal theory you’ll find, to the careful construction of
exposure hierarchies. Even as you venture into especially
challenging areas such as suicidality or moral injury, Russ Harris
provides a solid framework and proven strategies for helping
clients with traumatic histories to live the life they want and
deserve. An absolute must for anyone doing this important work.”
—Chris McCurry, PhD, clinical psychologist, and author
of Parenting Your Anxious Child with Mindfulness and
Acceptance

“This book is full of wonderful guidance on how to help those

with post-traumatic stress disorder (PTSD), and provided me with
many new exercises and insights into this disorder. If you work in
this area, read this book.”
—Michael P. Twohig, professor at Utah State University,
and coauthor of ACT in Steps

“A trademark of Russ Harris is his ability to break ACT down

into language that’s clear, pragmatic, and clinically useful, and to
illustrate ideas with great practitioner-client dialogue. And
Trauma-Focused ACT is no exception. What jumped out at me
with this book was how thoroughly it explores the nuances of
ACT in the context of trauma. If you are after guidance about
how to use ACT in this domain, then this book leaves no stone
unturned.”
—Nic Hooper, senior lecturer of psychology at University
of the West of England, and author of The Unbreakable
Student

“Trauma-Focused ACT is a great book. It speaks to therapists in a

really accessible way, helping them to understand trauma in a way
that will be supremely useful to their clients. The book gives a
wide range of tools and strategies that are psychologically well-
informed, compassionate, and based on solid scientific evidence.
The book integrates perspectives from neuroscience, psychology,
and a number of forms of evidence-based psychotherapy—all
from within a coherent ACT framework. This book is an essential
resource for all therapists.”
—David Gillanders, head of clinical psychology at the
University of Edinburgh

“Russ Harris has once more written a simple, practical,

comprehensive, easy-to-follow, state-of-the-art textbook that is an
essential read for both novice and experienced clinicians. Each
chapter is rich with examples, transcripts, metaphors, worksheets,
tips, and common pitfalls that enable the reader to both deliver
the intervention with confidence and gain a deeper understanding
of the ACT model and approach to trauma. Couching the whole
approach in cutting-edge research adds to the value of this book
as a great resource and an absolute must-have in any clinician’s
toolbox.”
—Maria Karekla, PhD, associate professor at University of
Cyprus, and coauthor of Cravings and Addictions

“I always appreciate Russ Harris’s books in their ability to clearly

communicate concrete, practically useful information on ACT in
an accessible way that’s helpful for newer and more advanced
practitioners alike. This book achieves that once again, containing
an impressive collection of insightful perspectives, tips, and
exercises that are coherently integrated within an overarching
model of delivering trauma-focused ACT (TFACT). It provides a
notably in-depth exploration of how ACT can be tailored to
individuals with trauma, including adaptations to common ACT
exercises, strategies for overcoming challenges, and integrating
other relevant theories in this area.”
—Michael Levin, PhD, associate professor at Utah State
University, and coeditor of Innovations in Acceptance and
Commitment Therapy
“Trauma-Focused ACT is essential reading for all ACT
practitioners working with clients who have experienced trauma.
The book provides cutting-edge and up-to-date coverage of ACT
theoretical concepts and practical innovations for practitioners.
Russ never fails to impress with his accessible yet theoretically
on-point exploration of the topic.”
—Louise McHugh, professor in the school of psychology at
University College Dublin, and coauthor of A Contextual
Behavioral Science Guide to the Self

“Russ Harris’s ACT publications are renowned for being

incredibly accessible and clinically useful. I can honestly say that
with Trauma-Focused ACT, Russ has outdone himself. At every
step along the journey, Russ generously offers modifications and
practical tips to help us when things don’t go according to plan,
while keeping us grounded in the science of ACT. Trauma-
Focused ACT is an important clinical resource that truly honors
the complexity of human suffering and the interpersonal
therapeutic endeavor.”
—Sheri Turrell, CPsych, peer-reviewed ACT trainer;
coauthor of ACT for Adolescents and The Mindfulness and
Acceptance Workbook for Teen Anxiety; psychoanalyst;
and adjunct lecturer at the University of Toronto

“This is an excellent, comprehensive, contemporary, and

instructive guide on how to conduct TFACT. Importantly,
consistent with the ACT framework, the TFACT approach is
sensitively person-focused, holistic, and open to incorporating
empirically supported strategies from different therapy models.
Russ describes TFACT in a very accessible and practical way,
with lots of illustrative therapist-client transcripts, worksheets,
and other useful clinical tools. This book will serve as an
excellent resource for clinicians at any level and from any
theoretical orientation in their delivery of empowering support to
people whose lives are constrained by the pain of trauma.”
 —Kenneth Pakenham, PhD, emeritus professor of clinical
and health psychology at The University of Queensland,
and author of The Trauma Banquet

“ACT is a powerful therapeutic approach to working with trauma

and its complex associated issues, such as complicated grief,
identity issues, and shame. Russ Harris has pulled together all the
latest cutting-edge research and practice into a manual that is
broad and deep in its theoretical and practical application. If you
work with clients who experience trauma, then this is a must-buy
for your bookshelf, that you will find yourself constantly reaching
for.”
—Joe Oliver, founder of Contextual Consulting, and
coauthor of The Mindfulness and Acceptance Workbook
for Self-Esteem

“I am profoundly grateful for this book. Russ Harris has applied

his masterful ability to make complex ACT concepts highly
accessible to the vitally important and often enigmatic treatment
of trauma. Filled with exercises, metaphors, and handouts, this
book offers dozens of fresh tools for your practice. The addition
of the essential physiological factors which often accompany
trauma is critical to the understanding of its treatment and is sure
to enrich your clinical conversations. Russ walks us through
dialogues with clients demonstrating a brilliant clinician’s
understanding of the importance of weaving compassion and
dignity into sessions. He will leave you with little doubt that you
can hold challenging sessions with trauma survivors. If you work
with clients with trauma, this is a must-read text.”
—M. Joann Wright, PhD, fellow of the Association of
Contextual Behavioral Science, peer-reviewed ACT
trainer, and coauthor of Learning ACT for Group
Treatment and Experiencing ACT from the Inside Out
“As a psychotherapist, whether you work with traumatized
patients or not, this book is for you. With his usual simple but
precise language, Russ Harris leads you through applying your
ACT skills to simple or complex trauma. This well-designed
model—based on four flexible stages of intervention—
encourages therapists to apply ACT according to personal style,
experience, and creativity.”
—Nanni Presti, professor at Kore University of Enna, Sicily

“Russ Harris did it again—gifting us a guide about a complex

clinical issue, written in a simple yet comprehensive way that
distills the latest insights about trauma-focused clinical work.
Trauma-Focused ACT is unique in its wide applicability: It will
give you a firm framework for your clinical work while also
leaving—and emphasizing—space and opportunities to flexibly
adapt the framework to each of your individual clients. For
experienced ACT therapists, it will be a source of inspiration how
to further tweak and refine their trauma-focused work.”
—Valerie Kiel, psychologist, and peer-reviewed ACT
trainer

“Russ Harris excels in making complicated stuff comprehensible.

If you have experience with ACT for some time and now want to
start working with people who have experienced trauma, this
book is for you. If you have worked treating people who have
experienced trauma and now want to start using ACT, this book is
for you. In a very structured yet flexible way, Russ Harris guides
you through the important aspects of trauma and the six core
processes of ACT. The work comes to life with the many case
examples and dialogues that help you understand how to address
important issues.”
—Jacqueline A-Tjak, PhD, clinical psychologist, and peer-
reviewed ACT trainer
“This manuscript is an invaluable resource for clients wrestling
with any form of traumatic experience—guiding them to get back
into their life, move beyond trauma, and find themselves again.
It’s written with so much compassion and knowledge, and it’s full
of resources that demonstrate—page by page—how ACT can
make a difference when working with trauma-related matters. If
you’re a clinician working with trauma, passionate about third-
wave therapies, this is a must-read book!”
—Patricia E. Zurita Ona, PsyD, author of The ACT
Workbook for Teens with OCD and Acceptance and
Commitment Therapy for Borderline Personality Disorder

“In the spirit of his go-to clinical text, ACT Made Simple, Russ
Harris has produced another vital and practical resource for
clinicians working with trauma. Trauma-Focused ACT presents a
user-friendly, yet sophisticated, model of case conceptualization,
treatment planning, and cutting-edge interventions derived from
ACT and informed by the latest science on trauma. Russ walks
the reader through countless case examples and clinical
exchanges to help translate principles into practice, emphasizing
the safety and willingness of the client throughout the stages of
therapy. Given the high prevalence and varied manifestations of
trauma across cultures and populations, this book is sure to be of
great value to clinicians.”
—Lou Lasprugato, marriage and family therapist, and peer-
reviewed ACT trainer

“Russ Harris has an unusual ability to describe the work of ACT

in a way that is both simple, clear, and profound. He has shown
this in his earlier books, and this one on treatment of trauma is yet
another example. The fact that he gives the concept of trauma a
wide definition makes the book highly relevant for most, if not
all, therapists working with psychological suffering.”
—Niklas Törneke, MD, coauthor of Learning RFT and The
ABCs of Human Behavior
 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
NEW HARBINGER PUBLICATIONS is a registered trademark of New Harbinger Publications,
Inc.
Copyright © 2021 by Russ Harris
Context Press
An imprint of New Harbinger Publications, Inc.
5674 Shattuck Avenue
Oakland, CA 94609
www.newharbinger.com
Cover design by Amy Daniel; Acquired by Catharine Meyers; Edited by Rona Bernstein; Indexed
by James Minkin
All Rights Reserved

Library of Congress Cataloging-in-Publication Data

Names: Harris, Russ, 1938- author.
Title: Trauma-focused ACT : a practitioner’s guide to working with mind, body, and emotion
using acceptance and commitment therapy / Russ Harris.
Description: Oakland, CA : New Harbinger Publications, [2021] | Includes bibliographical
references and index.
Identifiers: LCCN 2021029333 | ISBN 9781684038213 (trade paperback)
Subjects: LCSH: Acceptance and commitment therapy. | Psychotherapist and patient. | Post-
traumatic stress disorder--Treatment.
Classification: LCC RC489.A32 H375 2021 | DDC 616.89/1425--dc23
LC record available at https://lccn.loc.gov/2021029333
 To my beloved Natasha: my friend, my companion, my advisor, my
supporter, my teacher, my mentor, my guide…and the absolute love of my
life. So many times, I wanted to give up— but you kept me going. So many
times, I was stuck—and you helped me out. Volim te zauvek.
 CONTENTS

PART ONE: What Is “Trauma-Focused ACT”?

1. Chapter One. The Many Masks of Trauma
2. Chapter Two. An ACT Model of Trauma
3. Chapter Three. Fight, Flight, Freeze, Flop
4. Chapter Four. Keeping It Safe
5. Chapter Five. The Choice Point
6. Chapter Six. The Journey Ahead

PART TWO: Beginning Therapy

7. Chapter Seven. Firm Foundations
8. Chapter Eight. Anchors Away
9. Chapter Nine. Flexible Sessions

PART THREE: Living in the Present

10. Chapter Ten. Slipping the Shackles of Fusion
11. Chapter Eleven. Heavy Lifting
12. Chapter Twelve. Leaving the Battlefield
13. Chapter Thirteen. Making Contact, Making Room
14. Chapter Fourteen. Self-Compassion
15. Chapter Fifteen. Knowing What Matters
16. Chapter Sixteen. Doing What Works
17. Chapter Seventeen. Undermining Problematic Behavior
18. Chapter Eighteen. Overcoming Barriers, Maintaining Change
19. Chapter Nineteen. When Things Go Wrong
20. Chapter Twenty. Compassionate, Flexible Exposure
21. Chapter Twenty-One. The Flexible Self
22. Chapter Twenty-Two. Working with the Body
23. Chapter Twenty-Three. Sleep, Self-Soothing, and Relaxation
24. Chapter Twenty-Four. Working with Shame
25. Chapter Twenty-Five. Moral Injury
26. Chapter Twenty-Six. Suicidality
27. Chapter Twenty-Seven. Finding the Treasure
28. Chapter Twenty-Eight. Building Better Relationships

PART FOUR: Healing the Past

29. Chapter Twenty-Nine. Supporting the “Younger You”
30. Chapter Thirty. Exposure to Memories
31. Chapter Thirty-One. Grieving and Forgiving

PART FIVE: Building the Future

32. Chapter Thirty-Two. The Path Ahead
33. Chapter Thirty-Three. TFACT as a Brief Intervention
34. Chapter Thirty-Four. Parting Words
35. Acknowledgments
36. APPENDIX A. Resources
37. APPENDIX B. Further Training
38. References
39. Index
 PART ONE:

What Is “Trauma-Focused ACT”?

 CHAPTER ONE.

The Many Masks of Trauma

“Trauma” is the Greek word for “wound,” and “psyche” is the Latin
word for “soul.” From these ancient words, we get both the clinical term
“psychological trauma” and the poetic term “soul wound.” The latter
term seems to convey much better the deep anguish and suffering so
commonly involved in trauma. The pain from these wounds—physical,
emotional, psychological, or spiritual—can impact every area of human
life, and the fallout is often devastating: shattered world views; a
fractured sense of self; loss of trust, security, or meaning; and the list
goes on.
Soul wounds may occur at any age. For some, the trauma starts in
childhood, at the hands of abusive caregivers. For others, it’s not until
adulthood that something tears their world apart. And when these life-
shattering events happen, they can affect anything and everything:
relationships, work, leisure, finances, physical health, mental health—
even the very structure of the brain.
In acceptance and commitment therapy (ACT), we work intensively
with every aspect of these soul wounds: cognitions, emotions, memories,
sensations, urges, physiological reactions, and the physical body itself.
And at times we will find this work intensely challenging. Inevitably, it
triggers our own painful thoughts and feelings: perhaps anxiety, sadness,
or guilt; perhaps frustration or disappointment; perhaps worry, self-
doubt, or self-judgment. But when we make room for our own
discomfort, dig deep into our compassion, and create a sacred
therapeutic space—a place where we stand side-by-side with our clients,
to help them heal their pasts, reclaim their lives, and build new futures—
then our work, though often stressful, is deeply rewarding.

What Is Trauma?
Somewhat surprisingly, while it’s easy to find a definition of
posttraumatic stress disorder (PTSD), it’s hard to find a clear definition
of trauma. So to ensure we’re on the same page, I’m going to share my
own. (This isn’t the “right” or “best” definition; it’s just one that I trust
works for our purposes.)
A “traumatic event” is one that involves a significant degree of
actual or threatened physical or psychological harm—to oneself or
others. This can include everything from miscarriage to murder; from
divorce, death, and disaster to violence, rape, and torture; from
accidents, injuries, and illnesses to the medical or surgical treatments for
those things. It may also include incidents where people instigate,
perpetrate, fail to prevent, or witness actions that violate or contradict
their own moral code.
A “trauma-related disorder” involves:

1. direct or indirect experience of traumatic events

2. distressing emotional, cognitive, and physiological reactions to
that experience
3. the inability to cope effectively with one’s own distressing
reactions

In this book, whenever I use the word “trauma,” it’s short for
“trauma-related disorder,” an umbrella term for a vast number of
problems resulting from trauma, including PTSD, drug and alcohol
problems, relationship issues, depression, anxiety disorders, personality
disorders, sleep disorders, moral injury, chronic pain syndrome, sexual
problems, aggression and violence, self-harming, suicidality,
complicated grief, attachment disorders, impulsivity, and more. (Indeed,
a clear diagnosis of PTSD is rare in comparison to the many other
presentations of trauma.)
Many of these problems mask the trauma history that underpins
them, leaving it deeply buried and long forgotten. And although we talk
of “simple” trauma (a reaction to one major traumatic event) or
“complex” trauma (relating to many traumatic events over a long period,
often starting in childhood), there are many shades of gray between these
extremes. However, no matter how simple or complex trauma may be, it
always involves three streams of symptoms, which continually flow in
and out of each other:

Reexperiencing traumatic events: People reexperience traumatic

events in a variety of ways, including nightmares, flashbacks,
rumination, and intrusive cognitions and emotions.
Extremes of hyperarousal and hypoarousal: Later, we’ll explore
these terms in depth; for now, let’s keep it simple. With clients,
rather than “hyperarousal,” we talk about “fight or flight mode,”
which gives rise to anger, irritability, fear, anxiety, hypervigilance,
difficulty sleeping, and poor concentration. Likewise, rather than
“hypoarousal,” we talk about “freeze or flop mode”: the
immobilization and shutting down of the body, which fosters
apathy, lethargy, disengagement, emotional numbing, and
dissociative states.
 Psychological inflexibility: The overarching aim of ACT is to
develop psychological flexibility: the ability to be present, focused
on and engaged in what we’re doing; to open fully to our
experience, allowing our cognitions and emotions to be as they are
in this moment; and to act effectively, guided by our values. More
simply: “be present, open up, and do what matters.”
The flipside of this is psychological inflexibility, which boils
down to:
cognitive fusion (our cognitions—including thoughts,
images, memories, schemas, and core beliefs—dominate
our awareness and our actions)
experiential avoidance (the ongoing attempt to avoid
or get rid of unwanted cognitions, emotions,
sensations, and memories—even when doing so is
problematic)
remoteness from values (lack of clarity about or
disconnection from our core values)
unworkable action (ineffective patterns of behavior that tend to
make life worse in the long term, such as social
withdrawal, self-harm, and excessive use of drugs)

loss of contact with the present moment (distractibility,

disengagement, and disconnection from thoughts and feelings)

These three streams of symptoms—reexperiencing trauma,

extremes of arousal, and psychological inflexibility—overlap and
reinforce each other in a myriad of complex ways, giving rise to a truly
vast range of clinical issues.

What Is Trauma-Focused ACT?

Trauma-focused ACT (TFACT) is neither a protocol nor a treatment for
one specific disorder, such as PTSD. It is a compassion-based, exposure-
centered approach to doing ACT, which is (a) trauma-informed: drawing
upon relevant fields, such as evolutionary science, polyvagal theory,
attachment theory, and inhibitory learning theory; (b) trauma-aware:
attuned to the possible role of trauma in a wide range of clinical issues;
and (c) trauma-sensitive: alert to the risks of experiential work,
especially mindfulness meditation.
TFACT has three interweaving strands that apply to all trauma-
related issues: living in the present, healing the past, and building the
future.

Living in the present. This is the lion’s share of our work in TFACT. It
includes helping clients learn how to ground and center themselves;
catch themselves disengaging or dissociating and bring their attention
back to the here and now; connect with and be “at home” in their body;
overcome debilitating hyperarousal and paralyzing hypoarousal; unhook
from difficult cognitions and emotions; practice self-compassion in
response to their pain; focus on and engage in what they’re doing;
interrupt dwelling on the past and worrying about the future; access a
flexible, integrated sense of self; narrow, broaden, sustain, or shift
attention as required; practice ACT-congruent emotion regulation; savor
and appreciate pleasurable experiences; and connect with, live by, and
act on their values. And it also includes skills training as required (e.g.,
assertiveness and communication skills) to enable values-based living.

Healing the past. Here we explore with clients how their past has
shaped their present thoughts, feelings, and behaviors and actively work
with past-oriented cognitions and the emotions that go with them. This
includes “inner child” work, exposure to traumatic memories,
forgiveness, and grieving.

Building the future. Here we use values-based goal setting, including

relapse-prevention plans, to help clients plan and prepare for the future.
Ideally, we’re aiming for “posttraumatic growth”: growing and changing
in positive ways through the ordeals of the past, and applying the
strengths, insights, and wisdom gained along the way, to build a better
future.
Why Use Trauma-Focused ACT?
Acceptance and commitment therapy was created in the mid-eighties by
Steven C. Hayes, Professor of Psychology at the University of Reno,
Nevada, and further developed by his two cofounders, Kirk Strosahl and
Kelly Wilson. Since that time, over 3,000 published studies—including
more than 600 randomized controlled trials—have shown ACT’s
effectiveness with a wide range of clinical issues, from PTSD,
depression, and anxiety disorders to substance use, shame, and chronic
pain (Boals & Murrell, 2016; Lang et al., 2017; Gloster et al., 2020;
Luoma et al., 2012).
Of particular note is some recent research by the World Health
Organization (WHO). Since 2016, the WHO has been rolling out ACT
programs in refugee camps around the world, and in 2020 its first
randomized controlled trial was published in The Lancet (Tol et al.,
2020). The results were impressive. The participants were South
Sudanese women in a Ugandan refugee camp. Most of them had
experienced repeated gender-based violence, as well as the horrors of
warfare and the ongoing stress of living in a camp of 250,000 refugees.
Yet just ten hours of ACT, delivered in a group program run by lay
facilitators, resulted in significant reductions in both PTSD and
depression.
However, aside from the evidence base, there are several other good
reasons to use ACT for trauma-related issues.

A transdiagnostic approach. TFACT is a transdiagnostic model based

on a small number of core processes that we can flexibly use with all
diagnoses in the Diagnostic and Statistical Manual of Mental Disorders
(DSM), including co-occurring disorders. For example, we could work
with a client experiencing chronic pain, PTSD, and alcohol problems—
and simultaneously target all those issues using the same few core ACT
processes. Given that trauma presents in so many ways and comorbidity
is common, such versatility is handy.

An exposure-based approach. TFACT includes exposure as a core

element. In layperson’s terms, exposure basically means deliberately
making contact with “difficult stuff” to learn new, more helpful ways of
responding to it. Inside our body, “difficult stuff” may include memories,
thoughts, images, feelings, impulses, sensations, urges, emotions,
numbness, and physiological reactions. Outside our body, “difficult
stuff” may include people, places, objects, events, or activities. Prior to
exposure, this “difficult stuff” triggers self-defeating patterns of
behavior, but during exposure, clients learn new, more flexible, life-
enhancing ways of responding.

An interpersonal approach. TFACT offers many ways to work at an

interpersonal level—including an explicit focus on what is happening in
the therapeutic relationship. This is good news, given that interpersonal
problems are so common in trauma.

An integrative approach. As we travel through the world of TFACT,

we’ll explore a number of different theories that integrate well with it,
including polyvagal theory, attachment theory, and inhibitory learning
theory. (But don’t worry—we won’t get bogged down in the minutiae;
we’ll explore these theories from a practical perspective: light on
technical jargon, heavy on clinical application.)

A compassion-based approach. Self-compassion is an integral part of

TFACT—an essential aspect of all work with trauma. This ability to
acknowledge our own pain and suffering and respond to ourselves with
genuine kindness is fundamental for healing and recovery and a
powerful antidote to shame.

A combined “bottom-up” and “top-down” approach. Early sessions

of TFACT are typically “bottom up” in their emphasis: working with the
physical body, emotions, feelings, sensations, somatic awareness,
autonomic arousal, and so on. Later sessions are typically more “top-
down”: focusing more on cognitive flexibility, values, goal setting,
action planning, and problem solving. However, most sessions include
both approaches; the proportion of each varies from session to session,
flexibly tailored to the needs and responses of each unique client.

A comprehensive approach. TFACT is a rich, multilayered, holistic

approach for working comprehensively with all aspects of simple or
complex trauma. Within this book you’ll learn principles and processes
for working with addiction, interpersonal problems, insomnia, self-harm,
suicidality, emotion dysregulation, flashbacks, traumatic memories,
dissociative states, a fractured sense of self…and a whole lot more.
However, you don’t have to be an ACT purist; if you wish to include
resources from other models, such as eye-movement desensitization and
reprocessing (EMDR) or prolonged exposure, you can! As we’ll explore
later, TFACT blends well with other models.

A brief approach. The demand for brief therapy is rapidly growing, and
practitioners face the ever-growing challenge of how to optimize
outcomes with as few treatment sessions as possible. Fortunately,
TFACT works well as a brief therapy. Most of the book assumes
standard therapy sessions of fifty minutes, with an average of ten to
twelve per client. Of course, some clients do need long-term therapy,
extending over years, but the majority respond well in shorter time
frames. Chapter thirty-three, “TFACT as a Brief Intervention,” covers
how to do TFACT in settings where you only have a few sessions, which
may even be as short as thirty minutes.

How to Use This Book

In writing this book, I assume you already know something about ACT:
that you’ve done at least a beginners’ level training or read an
introductory textbook. Therefore, I have not included accounts of how
ACT was developed or in-depth descriptions of basic theory. So if you’re
brand new to ACT, you will be able to pick it up as you go—but I
recommend you first read the whole book, cover to cover, before using
it. (This is because the core ACT processes are interdependent, so if you
don’t have a grasp of the whole model and the way these processes
interact, you’ll likely get stuck.) And then, if you like the approach,
immediately work through an introductory level ACT textbook to build
up the essential foundational knowledge that isn’t covered here.
(On that note, I assume many readers have already read my own
introductory level textbook, ACT Made Simple (Harris, 2019), so I’ve
done my best to minimize overlap. Inevitably, there is some, but there’s
also a whole lot of brand-new stuff: many new topics, tools, techniques,
and methods for working flexibly with function and process. And where
I’ve revisited a favorite practice, such as “dropping anchor,” I’ve taken it
in a new direction with a clear trauma focus.)

EXTRA BIT I’ve written a free e-book called Trauma-Focused

ACT—The Extra Bits, which you can download from the “Free
Resources” page on http://www.ImLearningACT.com. There
you’ll find links to all the worksheets and handouts featured in
this book, as well as scripts for exercises and metaphors,
YouTube videos, and MP3 audio recordings. In most chapters,
you’ll find an “Extra Bits” box like this one, which lists all the free
materials in the corresponding chapter of the e-book. For
example, in chapter one of Extra Bits, you’ll find a PDF on “ACT
and Telehealth,” which shows you how to adapt everything in
this textbook for both audiovisual and audio-only telehealth.

Structure
There are five parts to the book. Part one, “What Is ‘Trauma-
Focused ACT’?” explores what trauma is and how to conceptualize and
work with it from an ACT perspective. Part two, “Beginning Therapy,”
covers the first two sessions, with an emphasis on setting up for maximal
effectiveness and safety. Parts three, four, and five cover the three
interweaving strands of TFACT: “Living in the Present,” “Healing the
Past,” and “Building the Future.”

Adapt Everything
As you go through this book, please adapt and modify everything to
suit your way of working. That includes metaphors, scripts, worksheets,
exercises, tools, techniques—everything! If you can think of a different
way to say or do something that would work better for you and your
clients, then go for it. Tap into your creativity; draw upon your
experience; make it your own.

Curiosity and Openness

The TFACT approach has many commonalities with other models
of trauma therapy—but also significant differences. So please bring an
attitude of curiosity and openness to your learning. If you read
something here that goes against your previous training, don’t
automatically dismiss it, but don’t automatically take it on board, either.
Instead, open to it; consider it; question it. Maybe it has a place in your
way of working—or maybe it doesn’t. No model is perfect; all have
strengths and weaknesses; so take what’s useful from this one, and leave
anything that’s not. And keep in mind the words of Carl Jung: “Learn
your theories as well as you can, but put them aside when you touch the
miracle of the living soul.”
 CHAPTER TWO.

An ACT Model of Trauma

Are you ready to dive into the deep and icy waters of case
conceptualization? In TFACT we conceptualize trauma somewhat
differently than in many other models, so it’s important to understand
this perspective, as it’s the foundation for all that follows. (A word of
caution for ACT newbies: this chapter introduces a slew of technical
terms, so if you find it daunting, don’t worry; it will all come together
later as we get into the clinical applications. And for experienced ACT
practitioners, a quick refresher never hurts, right?) Before we get into the
ACT model of trauma, I’ll give a quick summary of ACT and some
useful exercises to illustrate key concepts to your clients.

A Brief Summary of ACT

Acceptance and commitment therapy is an existential, humanistic,
mindfulness-based, cognitive behavioral therapy. In everyday language,
the aim of ACT is to help people reduce psychological suffering and
build rich, meaningful lives. It does this through helping us to:

learn new psychological skills to reduce the impact of difficult

emotions and cognitions—so they can’t push us around, hold us
back, or get in the way of life
 clarify our values (how we want to treat ourselves, others, and the
world around us) and use them to guide our actions and enhance our
life
focus attention on what is important and engage fully in whatever
activity we do

The Six Core Processes of ACT

Based on a philosophy of science known as functional
contextualism and a theory of language known as relational frame
theory, the ACT model rests on six core processes, illustrated in the
diagram below. (This is often playfully called “the hexaflex.”)

The ACT Hexaflex

CONTACT WITH THE PRESENT

MOMENT (BE HERE NOW)
Contacting the present moment means flexibly paying attention to
our here-and-now experience: narrowing, broadening, sustaining, or
shifting our attention, as desired. This involves consciously paying
attention to the physical world around us or the psychological world
within us, connecting with and engaging fully in our experience.

ACCEPTANCE (OPEN UP)

 Acceptance means willingly making room for unwanted private
experiences, such as cognitions, emotions, memories, urges, and
sensations. (The term “private experience” refers to any aspect of our
inner psychological world.) Instead of fighting, resisting, or running
from these unwanted experiences, we open up and give them space;
allow them to freely flow through us.
Note that acceptance does not mean passively accepting a difficult
situation; ACT advocates committed action to improve difficult
situations, or to leave them—whichever is the better option. Acceptance
means “experiential acceptance”: accepting private experiences.

DEFUSION (WATCH YOUR THINKING)

Defusion (short for “cognitive defusion”) involves learning to
notice, acknowledge, and separate from our cognitions; to “step back”
and observe them, instead of being dominated by them. We see our
cognitions for what they are—constructions of words or pictures or both
—and allow them to be present. We don’t challenge them, distract from
them, or push them away; instead, we hold them lightly. We allow them
to guide us when useful, but we don’t allow them to dominate us.
(Defusion and acceptance are interwoven: we make room for our
cognitions, and allow them to freely come and stay and go, in their own
good time. And we defuse from cognitions, which pull us into a struggle
with our inner experience—This feeling is terrible! I have to get rid of
it!)

SELF-AS-CONTEXT (THE NOTICING

SELF)
In everyday language, we talk about two parts of the mind. There’s
a part that thinks—generating thoughts, beliefs, memories, fantasies, and
so on. And there’s another part that silently notices, focuses, pays
attention; that’s aware of what we’re thinking, feeling, sensing, or doing
in any moment. Technically, we call this “self-as-context,” but clinically,
we use terms like the “noticing self,” “observer self,” or “the part of you
that notices.”
 To confuse matters, there’s a second meaning of self-as-context. It’s
a synonym for “flexible perspective taking”—the cognitive process that
underpins defusion, acceptance, contacting the present moment, self-
awareness, self-reflection, compassion, theory of mind, empathy, the
noticing self, imagining yourself in the future or the past, seeing things
from other people’s viewpoints, and a whole lot more. In this book, we’ll
use both meanings at different times.

Practical Tip
In the ACT model, there are four core mindfulness processes:
contact with the present moment, defusion, acceptance, and
self-as-context. So the term “mindfulness” may refer to any one
of (or a combination of) these processes.

VALUES (KNOW WHAT MATTERS)

Values are desired qualities of behavior: how you want to treat
yourself, others, and the world around you. They describe how you want
to behave in your relationships with anyone or anything—now, and
ongoing. We can use our values for inspiration, motivation, and
guidance. Like a compass, they give us direction and help us find our
way when we are lost.

COMMITTED ACTION (DO WHAT IT

TAKES)
Committed action means taking effective action, guided by our
values, to build a life that’s rich, full, and meaningful. This includes goal
setting, action planning, problem solving, and exposure. It also includes
learning and applying any skill that enhances life—from self-soothing
and relaxation to interpersonal skills such as assertiveness,
communication, and conflict resolution.
 Psychological Flexibility
As you can see in the figure above, the core processes are
interconnected elements of “psychological flexibility”: the ability to act
effectively, mindfully guided by values. The greater our psychological
flexibility—our ability to be fully conscious, open to our experience,
acting in line with our values—the greater our quality of life.
Psychological flexibility enables us to respond effectively to our
problems, develop a deep sense of meaning and purpose, and engage
fully in life here and now.
Self-compassion, a fundamental, intrinsic aspect of ACT, doesn’t
get listed on the hexaflex because it actually involves all six processes;
we’ll explore this in chapter fourteen.

The ACT Triflex

We can lump the six core processes into three larger units, as shown
in the figure below, which is playfully known as “the triflex” (Harris,
2009a).

The ACT Triflex

Self-as-context and contact with the present moment both involve

flexibly paying attention to and engaging in your here-and-now
experience (in other words, “Be present”).
Defusion and acceptance both involve noticing thoughts and
feelings, seeing them for what they truly are, making space for them, and
 allowing them to freely come and go of their own accord (in other
words, “Open up”).
Values and committed action both involve initiating and sustaining
life-enhancing action (in other words, “Do what matters”).
So we can describe psychological flexibility as the ability to “be
present, open up, and do what matters.”

Two Useful Exercises

The following exercises are extremely useful for introducing key ACT
concepts, and we’ll refer back to them in later chapters. (Both work well
in telehealth; see the PDF “ACT and Telehealth” in chapter one of Extra
Bits.) As you read them, I encourage you to act them out, speaking the
words aloud; this will be a much richer learning experience than simply
reading them. The scripts are “bare bones”; in session, we flesh them out
with specific examples drawn from the client’s life. For example, after
the line “…the difficult problems and challenges you need to deal
with…,” we would mention one or two of the client’s problems (e.g.,
“the conflict with your kids” or “the ongoing treatment for your
injuries”).

Hands as Thoughts
The Hands as Thoughts exercise (Harris, 2009a) demonstrates the
costs of fusion (“getting hooked” by thoughts) and benefits of
defusion (“unhooking”). We do all the actions mentioned in the script,
inviting the client to copy us.
Therapist: Would you be willing to do a quick exercise with
me, to give you a sense of what we’re aiming to do
next?
Client: Sure.
Therapist: Okay, (points to an area of the room in front of
the client) well, imagine that in front of you is
everything that’s truly important to you. All the
pleasant stuff that’s important—like the people,
and places, and activities you love; your favorite
food, music, sports, and movies; and so on (gives
some examples specific to the client). And, also,
all the painful stuff: the difficult problems and
challenges you need to deal with, and all the
difficult tasks you need to do (gives some
examples specific to the client). And put your
hands together like this (therapist puts hands
together, palms upward, as if an open book; client
copies) and imagine that these hands are your
thoughts and feelings.
Client: Okay.
Therapist: So copy me, and let’s see what happens when
we get hooked by our thoughts and feelings.
(Therapist slowly raises their hands toward their
face; client copies.) That’s it, and bring them right
up so they’re covering your eyes. (Both continue
the motion, until both have their hands touching
their faces—covering up their cheeks, eyes, and
foreheads.)
So this is what it’s like when we’re hooked by
our thoughts and feelings. And notice three things.
(Both therapist and client keep their hands over
their eyes.) One. Look around the room, and
notice: How much are you missing out on? How
cut off and disconnected are you from all the
important stuff out there?
Client: A lot!
Therapist: You’re not kidding. Now two—notice: How
difficult is it to focus on things? Imagine the task
 you need to do, or the person you love, is in front
of you right now; how hard is it to give them your
full attention?
Client: Bloody hard!
Therapist: For sure. And three—notice: How difficult is it to
take action, to do the things that make your life
work? How hard to drive a car or cook dinner or
type on a computer (gives a few mores examples
specific to the client)?
Client: Yeah, you can’t do it.
Therapist: Okay. So that’s what happens when we get
hooked. Now once again, copy me, and let’s see
what happens when we unhook from our thoughts
and feelings. (Therapist, ever so slowly, lowers
their hands from their face and rests them in their
lap; client copies.)
Therapist: So notice: How much more can you take in?
How much easier is it to engage and connect; to
keep your attention focused on the task at hand?
(Client nods, agrees.)
And move your arms around. (Therapist waves
their arms around; client copies) How much easier
is it now to do the things that make your life work;
to drive a car, or type on a computer, or cook
dinner (therapist mimes these activities while
mentioning them)?
Client: A lot!
Therapist: And notice these things (therapist moves their
hands around) haven’t disappeared. They’re still
here. So if you can use them, do so. Because
even really difficult thoughts and feelings can give
us valuable information about things we need to
 deal with or do differently. But if you can’t make
any good use of them, you just let them sit there.

Pushing Away Paper

The Pushing Away Paper exercise (Harris, 2011) illustrates the costs
of experiential avoidance and the benefits of acceptance. (This
exercise involves strenuous effort with the arms, so it is unsuitable
for any client or practitioner with neck, shoulder, or arm problems. A
good nonphysical alternative is the Struggle Switch metaphor in
chapter twelve.)
In this exercise, the client and therapist each have a sheet of
paper.
Therapist: Imagine that in front of you is everything that’s
truly important to you. All the pleasant stuff that’s
important—like the people, and places, and
activities you love; your favorite food, music,
sports, and movies, and so on (gives some
examples specific to the client). And, also, all the
painful stuff: the difficult problems and challenges
you need to deal with, and all the difficult tasks you
need to do (gives some specific examples). And
imagine this sheet of paper is all your difficult,
unwanted thoughts, feelings, urges, and
memories.
Client: Okay.
Therapist: So let’s see what happens when we struggle with
this stuff. Are you okay to copy me? (Therapist
grips the paper tightly with both hands, one on
either side; client copies.) Great. Now keeping a
tight hold, push it away from you, as hard as you
can. (Both client and therapist extend their arms.)
This is what everyone tells you to do, right?
Friends, doctors, therapists? Get these thoughts
and feelings away from you!!
But you know—it doesn’t look like we’re trying
very hard here (therapist says this humorously and
playfully). How about we push a bit harder. (Both
client and therapist push harder.) That’s it—
straighten those elbows; get those thoughts and
feelings as far away as you possibly can. (Client
and therapist maintain this posture for the next
section of the exercise: holding the paper tightly by
the edges, arms straight, as far from the chest as
possible.)
Now notice three things. First, how tiring is
this? We’ve only been going for less than a
minute, and already it’s tiring. Imagine doing this
all day; how much energy would it consume?
Second, notice how distracting it is. If the
person you love were right there in front of you,
how hard would it be to give them your full
attention? If your favorite movie were playing on a
screen over there, how much would you miss out
on? If there’s an important task in front of you right
now or a problem you need to address or a
challenge you need to tackle, how hard is it to
focus on it?
Third, notice while all your effort and energy is
going into doing this, how hard it is to take action,
to do the things that make your life work, such as
(therapist gives some examples based on the
client’s history). So notice how difficult life is when
we’re struggling with our thoughts and feelings like
this. We’re distracted, we’re missing out on life, it’s
hard to focus, we’re exhausted, and it’s so hard to
do the things that make life work.
Now, let’s see what happens when we drop the
struggle with our thoughts and feelings. (Therapist
relaxes their arms, drops the paper into their lap.
 The client copies the therapist and expresses a
loud sigh of relief.) Big difference, huh? How much
less tiring is this? How much more energy do you
have now? How much easier is it to engage with
and focus on what’s in front of you? If your favorite
person were in front of you right now, how much
more connected would you be? If your favorite
movie were playing, how much more would you
enjoy it? If there were a task you needed to do or a
problem you needed to address, how much easier
would it be to focus on it?
Now move your arms and hands about—
(therapist gently shakes their arms and hands
around; client copies). How much easier is it now
to take action: to cuddle a baby, play tennis, hug
the person you love?
And notice these things (therapist indicates the
paper in their lap) haven’t disappeared. We haven’t
gotten rid of them. They’re still here. But we’ve got a
whole different way of responding to them. We’re
handling them differently. They’re no longer holding
us back, or bringing us down, or jerking us around.
And if there’s something useful we can do with them,
we can use them. Because even really painful
thoughts and feelings often have information that can
help us—even if it’s just pointing us toward problems
we need to address or things we need to do
differently. And if there’s nothing useful we can do
with them, we just let them sit there.

Note that in both of the above exercises, there is no intention to get

rid of thoughts and feelings; at the end, the hands remain, as does the
paper. Similarly, in both exercises we point out that even the most
painful thoughts and feelings are often useful; provided we respond to
them mindfully, we can often use them constructively to improve our
lives. But this will not be possible if we are fused with or trying to avoid
them. Finally, both exercises also clarify that there are two main
purposes for learning these new skills: (a) to enable effective values-
based action, and (b) to help your client focus attention on what’s
important.

Practical Tip
Clients won’t learn defusion or acceptance simply from doing
these exercises. These are psychoeducational metaphors. We
always need to follow them with active training in defusion or
acceptance skills.

Now that we’ve covered the ACT basics , let’s explore how to
conceptualize cases.

Case Conceptualization in TFACT

The eight-part case conceptualization that follows is suitable for clients
with any type of trauma-related disorder. First, an important note: When
gathering information, we don’t work through a case conceptualization
form, completing each section sequentially; we complete these forms
outside of session, to organize our thoughts or create treatment plans.
Taking a history is a nonlinear process, gathering bits and pieces here
and there, compiling it over time. So we’d rarely obtain all of the below
information at intake; usually it spills over into session two. But the
excellent news is, we don’t have to know all this information before we
start doing TFACT. We can get the broad strokes at intake and gather
more details later, as relevant.
As you read through this, keep in mind a client you’re currently
seeing, and at the end of each section, pause for a few moments and
reflect on how this applies. (Better still, download the case
conceptualization worksheet from Extra Bits, and fill it in as you go.)
 Part 1: Client’s Therapy Goals
In chapter seven, we’ll explore how to establish goals for therapy—
and why they are so important. They fall into three broad classes:
A. emotional goals (how the client wants to feel different, for
example, to feel happy, to feel less anxious, to get rid of unwanted
thoughts and feelings)
B. behavioral goals (what the client wants to do differently, for
example, to exercise more, to be more supportive to their family)
C. outcome goals (what the client wants to have, get, or achieve,
for example, find a partner, get a job, leave a relationship, recover
from an illness or injury)
What are your client’s goals in each of these categories?

Part 2: Past History

Although TFACT has a strong here-and-now focus, working with
the past is also important. What traumatic events have played a
significant role in current issues? Was there any childhood trauma? Have
other major life events—not necessarily traumatic, but disruptive and
stressful—precipitated the current presentation?

Part 3: Physical Barriers

Are there physical barriers (as opposed to psychological) holding
the client back from a rich and meaningful life? For example, are they in
a dangerous environment, such as a prison or crime-ridden
neighborhood? Or exposed to racism, victimization, prejudice, social
injustice, harassment, sexual discrimination, religious persecution,
bullying, rejection, or violence? Or involved in dysfunctional
relationships? Or doing a job (e.g., emergency services) that regularly
exposes them to traumatic events? Or social, medical, financial, legal,
occupational, or domestic problems?
 Part 4: Reexperiencing Trauma and
Abnormal Arousal
Clients reexperience traumatic events in a variety of ways,
including flashbacks, nightmares, intrusive emotions, and cognitions,
dwelling on painful memories and ruminating on past events. These
private experiences are unpleasant and distressing, and they trigger the
threat response systems of the autonomic nervous system.
The best known of these systems is the “fight or flight” response:
the sympathetic nervous system perceives a threat and kicks us into a
state of high alert, preparing us to flee or attack. This state of
hyperarousal gives rise to symptoms such as excessive sweating, muscle
tension, rapid heart rate, palpitations, hypervigilance, exaggerated startle
response, irritability, difficulties concentrating or sleeping, and emotions
related to fleeing (such as fear, anxiety, panic) or to fighting (frustration,
anger, rage).
If a stimulus is perceived as life threatening, and the person’s
attempts to attack or flee appear futile, then the parasympathetic nervous
system activates the “freeze”—or “emergency shutdown”—response;
this prepares the person to lie down, stay quiet and still, and give up any
attempt at escape. This state of hypoarousal gives rise to symptoms such
as numbness, lethargy, apathy, boredom, disengagement, and
dissociation.
All of these private experiences are unpleasant and distressing in
themselves. But what makes their negative impact so much greater is the
myriad of inflexible ways that humans respond to them collectively,
known as psychological inflexibility. This constitutes the third stream of
symptoms in trauma-related disorders, and the next few parts of the case
conceptualization explore its key elements: cognitive fusion, experiential
avoidance, loss of contact with the present moment, remoteness from
values, and unworkable action.

Part 5: Cognitive Fusion

 Cognitive fusion means that cognitions dominate our awareness or
actions (or both). When we fuse with cognitions, they seem like:

commands we need to obey

something important, requiring our full attention
threats to our health and well-being
advice we should follow
statements of absolute truth

Fusion is usually problematic because it tends to interfere with

living one’s values, acting effectively, and engaging in life. Six
categories of fusion show up repeatedly: past, future, self, judgments,
rules, and reasons.

FUSION WITH THE PAST AND FUTURE

Fusion with past-oriented cognition includes dwelling on painful
memories, going over old hurts and mistakes, grieving for what has been
lost, feeling resentment or regret, ruminating, blaming oneself or others,
or dwelling on how good life was before the trauma.
Fusion with future-oriented cognition includes worrying,
catastrophizing, and predicting the worst. The future seems scary or
bleak: bad things will happen; people will hurt you, abandon you, or let
you down; life will be empty and miserable.
And often past and future overlap: what happened in the past will
happen again in the future.

FUSION WITH SELF-CONCEPT

“Self-concept,” or “the conceptualized self,” are terms that refer to
all the thoughts, beliefs, and ideas we have about who we are and how
we got that way. In the case of trauma, clients typically fuse with a
negative self-concept: I’m not good enough, I’m broken, I’m damaged,
I’m disgusting, I’m unworthy, I’m hopeless, I’m useless, I deserved it,
I’m to blame, and so forth.
When past traumatic events become central to a person’s identity
and life story, this is technically termed “event centrality”; clients
believe they have been irreparably damaged or tainted by their trauma; it
defines who they are: worthless, unlovable, defective, and so on.
Some clients fuse with an impoverished self-concept: I have no idea
who I am, I’m nothing, I’m no one. Others avoid a threatening negative
self-concept through fusion with an excessively positive self-concept:
narcissism. And occasionally people fuse with multiple conceptualized
selves: the different “personalities,” “identities,” or “alters” of
dissociative identity disorder.

FUSION WITH JUDGMENTS

Clients often fuse with judgments about life (it sucks, it’s pointless),
the world (it’s unsafe, dangerous, evil), other people (they don’t care, you
can’t trust them), themselves (I’m to blame, it’s my fault). They also fuse
with judgments about their own cognitions, emotions, and memories
(they are awful, horrible, unbearable; I can’t stand them), which in turn
feeds negative self-concept (these awful thoughts and feelings show how
damaged I am).

FUSION WITH RULES AND REASONS

Rules are often useful; it’s good to know which side of the road we
have to drive on. But when we fuse with rules, our behavior becomes
rigid and inflexible. Our cognitive rules often contain words like
“should,” “have to,” “must,” “need,” “ought,” or terms and conditions
like “only if,” “can’t unless,” “shouldn’t because,” “won’t until.” Some
common examples: “I must do it perfectly—and if I can’t, there’s no
point in doing it,” “I have to drink to cope,” “You can’t trust men,” “I
shouldn’t let people get close because they’ll hurt me.” The greater the
fusion with rules, the stronger the compulsion to follow them—and the
greater the anxiety when bending or disobeying them.
 Rules overlap with reasons: all those cognitions about why we can’t
change, shouldn’t change, or shouldn’t even have to change: I can’t do it,
it’s too hard, I don’t have the time, I don’t have the energy, it’ll go wrong,
I’ve tried before and I always fail, it’s too scary, I’m too depressed, and
so on. And of course, if we fuse with these reasons, then we don’t
change.

FUSION WITH NARRATIVES, SCHEMAS,

AND CORE BELIEFS
All the categories of fusion above—past and future, self-concept,
judgments, rules and reasons—combine to create complex narratives,
schemas, and core beliefs. Here is a trauma-related example: Because
these terrible things happened to me (past), I’m damaged goods
(judgment, self-concept), which is why I keep taking drugs (reason), and
I can’t stop taking them because I need them to cope (rule), so life is
pretty shitty (judgment), and I can’t see it getting any better (future).
In particular, look out for fusion with the following belief system,
which underpins experiential avoidance: These thoughts and feelings are
bad, unnatural, and unbearable (judgment); they mean that there’s
something wrong with me (self-concept); and I can’t get on with my life
until they are gone (reason); so I have to get rid of them (rule).

Part 6: Experiential Avoidance

Experiential avoidance (EA) is the ongoing attempt to avoid or get
rid of unwanted private experiences (e.g., cognitions, emotions,
sensations), even when doing so is harmful. EA is normal, and
everybody does it. We only target EA in therapy when it becomes
excessive, rigid, or inappropriate to such an extent that it negatively
impacts the client’s health and well-being or gets in the way of doing
things that make life meaningful. (Please remember this; we aren’t
mindfulness fascists, insisting people must always accept all private
experiences.)
 Clients have all sorts of painful cognitions and emotions, which
they naturally want to avoid or get rid of—and by the time they come to
therapy, they’ve usually discovered many different strategies for doing
so, including drugs, alcohol, gambling, social withdrawal, people
pleasing, self-harming, suicidality…and the list goes on.
Note that we only label behavior “experientially avoidant” if its
primary aim is to avoid unwanted inner experiences. If you go to the
gym primarily motivated by values around self-care and goals around
improving physical health, that is not experientially avoidant. But if your
primary motivation is to avoid emotional discomfort (e.g., to avoid
feelings of anxiety or thoughts about getting fat), then it is experientially
avoidant. (Obviously, all behaviors have multiple motivations, so we’re
talking about which predominates.)
At times, EA is ineffective but harmless. And at other times—used
flexibly, moderately, and appropriately—it can be life enhancing. But
when EA is excessive, rigid, or inappropriate, it usually makes life
worse rather than better. For example, higher levels of EA mediate the
relationship between traumatic events and general psychological distress,
predict severity of symptoms across a range of disorders, increase the
likelihood of substance use relapse, and mediate the relationship between
maladaptive coping strategies and psychological distress (Chawla &
Ostafin, 2007). Among people experiencing posttraumatic stress, those
with higher levels of EA report less posttraumatic growth and meaning
in life and attenuated well-being (Kashdan & Kane, 2011). And in
veterans both with and without PTSD, the more focused they were on
experiential avoidance and emotion regulation, the worse their mental
health was (Kashdan et al., 2010).

Part 7: Loss of Contact with the

Present Moment
In trauma, we see significant loss of contact with the present
moment. We can think of this in terms of the three Ds: Distractibility,
Disengagement, and Disconnection from your inner world.
Distractibility. Many clients find it hard to focus. They get easily
distracted by their thoughts, feelings, and memories, and their attention
wanders away from the task at hand.

Disengagement. This refers to “going through the motions”—being

emotionally distant from or uninterested in one’s current activity. For
example, clients may eat their food without noticing or appreciating the
taste, or talk to a loved one without any interest in the conversation, or
perform a task on “automatic pilot” with little conscious awareness.
Social disengagement is especially common, with many clients reporting
feeling cut off or emotionally distant from their loved ones.

Disconnection from the inner world. The third D is for disconnection

from one’s inner world. Some clients are very disconnected from their
cognitions, unable to tell us what they are thinking. Others are
disconnected from their emotions—unable to tune into them, identify
them, or label them accurately. The more disconnected you are from
your inner world, the harder it is to “know yourself,” meaning the less
your self-awareness or insight.

Part 8: Remoteness from Values

As fusion and avoidance consume our clients’ lives, they become
ever more remote from their values. Common values that get lost are
self-care, caring for others, intimacy, courage, trust, assertiveness,
independence, playfulness, gratitude, compassion, and responsibility—
but of course, this varies hugely from person to person. For some, this
remoteness from values is because their life has been so focused on
survival and avoiding pain, they’ve never had the opportunity to reflect
on their values. For others, it happens because of fusion with rigid rules;
this pulls them away from the lush tropical landscape of values into the
harsh barren wasteland of should, must, and have to.

Part 9: Unworkable Action

 When actions effectively make life richer and more meaningful, we
describe them as “workable.” On the other hand, “unworkable actions”
(behaviors that often meet short-term needs but worsen life in the long
term) commonly result from fusion, experiential avoidance, or both. For
example, problematic use of drugs or alcohol is usually maintained by
(a) attempts to avoid painful cognitions and emotions, and (b) fusion
with several categories of cognition, such as reasons (“I need this to
cope”), self-concept (“I’ve got an addictive personality”), or judgments
(“It’s not harmful”).
“Away moves” is a popular term for unworkable actions because
they take you away from the person you want to be and the life you want
to build. Away moves are anything the client does that makes life worse,
keeps them stuck, worsens problems, inhibits growth, prevents effective
solutions, and impairs health and well-being.
The negative long-term consequences of unworkable action give
rise to even more painful thoughts and feelings, which fuel even more
fusion and avoidance: a chronic vicious cycle.

Practice, Practice, Practice

You don’t need me to tell you this—but I’m going to anyway,
because that’s the kind of annoying person I am. (Did you note the
fusion with self-concept there?) If you want to do TFACT well, reading a
book won’t cut it; you have to practice, practice, practice; and then
practice some more. So please download a case conceptualization
worksheet from Extra Bits, and fill it in for a current client. Once
complete, place it alongside the hexaflex or triflex diagram presented
earlier in this chapter, and, looking from one to the other, carefully
consider: which ACT processes apply to which aspects of your client’s
difficulties?
I recommend you fill out at least one of these worksheets every day,
because the better you conceptualize trauma from a TFACT perspective,
the more effective you’ll be in session.
 EXTRA BIT Please download the free e-book Trauma-Focused
ACT: The Extra Bits from the “Free Resources” page on
http://www.ImLearningACT.com. In chapter two, you’ll find
printable versions of the hexaflex and triflex, a case
conceptualization worksheet, and scripts for both Hands as
Thoughts and Pushing Away Paper.

Takeaway
ACT is a type of cognitive behavioral therapy that creatively uses values
and mindfulness skills to help people reduce psychological suffering and
build meaningful lives. It achieves this through developing
psychological flexibility: our ability to focus on and engage in what we
are doing, to acknowledge and allow our cognitions and emotions to be
as they are, and to act effectively, guided by our values. In other words:
“be present,” “open up,” “do what matters.”
ACT is a transdiagnostic approach, which enables us to
conceptualize any clinical issue in terms of psychological inflexibility:
cognitive fusion, experiential avoidance, loss of contact with the present
moment, remoteness from values, and unworkable action. This makes it
well-suited for the huge range of problems related to trauma, and the
best way to understand its versatility is to do lots and lots (and lots) of
case conceptualization.
 CHAPTER THREE.

Fight, Flight, Freeze, Flop

All too often, our clients interpret their difficult cognitions, emotions,
and physiological reactions as signs of being weak, defective, or crazy.
So if we can help clients make sense of these experiences and reframe
them as attempts of the mind, brain, and body to keep us safe and protect
us from harm, we can pave the way for acceptance and self-compassion.
Ideally, we begin this work on the very first session.

The Science Behind Our Responses

The autonomic nervous system regulates our body’s internal organs. It
has two parts: the sympathetic nervous system (SNS), which “stirs us
and speeds us up,” and the parasympathetic nervous system (PNS),
which “stills us and slows us down.” These systems are the basis for why
we respond to threats as we do.

Fight or Flight
When we perceive danger, the SNS activates “fight or flight” mode,
preparing us to either resist the threat or flee from it. Among other
changes, many large muscles tense up, ready for action; the heart and
lungs speed up to pump well-oxygenated blood to the muscles; and the
hormone cortisol is released, raising blood glucose levels to provide lots
of energy. In fight or flight mode, the SNS gives rise to emotions such as
fear, anxiety, panic, irritation, anger, and rage. The SNS gets its name
because of these feelings; “sympathetic” is derived from the Greek
words syn and pathos—meaning “with feelings.”

Polyvagal Theory
Para is the Greek word for “against”; the PNS gets its name
because it “goes against” the SNS. Remember, while the SNS stirs and
speeds us, the PNS stills and slows us. The vagus nerve is the largest
nerve in the PNS. It gets its name from the Latin word vagus, which
means “wandering”; it “wanders around” the body, innervating many
different organs and areas, especially in the face, chest, and abdomen. To
understand the role of the PNS in trauma, we can turn to the hugely
influential polyvagal theory (PVT; Porges, 1995). Poly is Greek for
“many”; PVT gets its name because the vagus nerve has many diverse
features and functions.
The vagus nerve has two main branches—dorsal (back) and ventral
(front)—and when we are not under threat, the ventral branch fosters a
state of “rest and digest,” where we can slow down, relax, socialize,
connect, and bond with others (and digest our food). I often call it
“share/care” mode, because it inclines us to be loving, caring, and
considerate; to share with, connect with, and look after others. When in
this mode, we experience feelings of warmth, calm, and contentment.
However, the moment we perceive a threat, the SNS takes over, and
we instantly switch from share/care to fight/flight: preparing to stand our
ground or run away. But what happens if the threat is so extreme that
fight or flight is futile, for example, if you’re helplessly pinned under a
rockslide, or you’re a child being savagely beaten by an adult?
When the threat is extreme and attempts to fight or flee are unlikely
to be useful, the dorsal branch of the vagus nerve takes the helm and
switches us into emergency shutdown mode. To conserve energy, the
PNS shuts down many physiological functions. It immobilizes the body,
slows down the heart and lungs, drops blood pressure, and pauses
nonessential activities such as digestion. In the early stages of shutdown,
someone may be “frozen stiff,” “rooted to the spot,” or “paralyzed with
fright.” But in more extreme shutdown, their legs may fail and they may
flop to the floor or even lose consciousness. We can call this either
“freeze/flop” or “emergency shutdown” mode: a state that fosters
dissociation, numbness, apathy, despair, and disinterest.

The “Fawn” Response

There’s a trend in trauma literature to write about four trauma
responses: fight, flight, freeze, and fawn. “Fawning” means working
hard to please and appease other people. A child may work hard to be “a
good kid” as a protective strategy when caregivers are abusive or
neglectful, and an adult may take “people pleasing” to extremes,
repeatedly neglecting their own needs, values, and boundaries in
relationships to gain approval and fulfill the needs of others. Personally,
I prefer not to bundle “fawn” with fight, flight, and freeze because the
latter are all automatic, instinctive responses of the autonomic nervous
system—whereas fawning is not.

Psychoeducation
Psychoeducation about these responses is important. When clients
understand what is going on in their bodies and why, those experiences
become less threatening, which facilitates acceptance. However, too
much psychoeducation can make for an intellectual session and eat up
valuable time that could be better spent on experiential work. So we
need to strike a balance. Beginning with a metaphor is a useful way to
start.

The Bear Metaphor

The Bear Metaphor is a simple and memorable way to convey the
key points discussed above. There are two versions: one for hyperarousal
and one for hypoarousal.

The Bear Metaphor: Fight/Flight

Therapist: Do you know much about the fight or flight
response?
Client: A bit.
Therapist: Would it be okay to talk about it for a couple of
minutes, to help make sense of what’s going on
with your body?
Client: Sure.
Therapist: Cool. Well, if you can, imagine one of your
caveman ancestors is out by himself hunting
rabbits, and suddenly he comes face to face with
this huge mother bear. And she’s got these two
young bear cubs by her side. So to her, this
human is a threat. So what does she do to protect
her cubs?
Client: She charges.
Therapist: Right, she charges. Hard and fast. She wants to
kill this guy—he’s a threat to her cubs. So if he
wants to survive, your ancestor’s only got two
options…
Client: Fight or flight!
Therapist: Right. So instantly his nervous system takes
over. And it’s not like he thinks, Uh oh—I’d better
switch into fight or flight mode. Before he can even
register a thought, his nervous system switches
into fight or flight mode. All those large muscles in
his arms and legs, chest and neck—they tense up,
ready for action, to fight or to run. His body floods
 with adrenaline, heart speeds up, pumping blood
to his muscles. He’s pumped to the max. You ever
feel like that?
Client: All the time.
Therapist: Yeah, and it takes a lot out of you, right? And
that’s because this fight or flight response is
supposed to be very short-lived—it’s supposed to
last just long enough to get you out of danger—
and then it’s supposed to switch off. But your
nervous system’s not doing that; the fight or flight
response isn’t switching off. So all that losing your
temper, getting angry about stuff, those tense
muscles in your neck and back—that’s your fight
mode working overtime. And the anxiety, fear,
sweating, getting startled—that’s your flight mode.
Same thing with your insomnia—when a bear’s
after you, you don’t want to be sleeping.
We can readily link any symptoms of hyperarousal to this metaphor.
So, for example, for trauma-related sexual problems such as erectile
dysfunction, loss of libido and anorgasmia, we can say, “When you’re
under threat, your nervous system switches off any part of the body
that’s not essential for survival. When a bear’s after you, having sex is
not a priority.”

Practical Tip
If clients don’t believe in evolution, we can change the language:
“ancient” ancestors rather than “cavemen”; “designed” rather
than “evolved.” We don’t even need to mention ancient
ancestors; we can just say “This is what your body does when
under threat.”

The Bear Metaphor: Freeze/Flop

 If hypoarousal is also an issue, we can extend the Bear Metaphor as
follows:
Therapist: So that’s fight or flight, but there’s another mode
your nervous system goes into, called freeze or
flop, or emergency shutdown mode. So let’s
suppose your ancestor throws his spear at the
bear, but misses. What’s he gonna do?
Client: Run for it.
Therapist: Right—so off he goes, pegs it as fast as he can.
But, you know, not even Usain Bolt can outrun a
bear.
Client: (laughs) Right.
Therapist: So the bear chases—and it’s furious—and it
catches the guy, throws him to the floor, gets stuck
into him—claws, teeth, the works—so at this point,
your ancestor’s only chance of survival is to be as
quiet and still as possible. If he fights back, or tries
to escape, the bear will hurt him even more. But if
he’s still and silent, then maybe, if he’s lucky, the
bear will lose interest, leave him alone—because
he’s not a threat anymore. But hey—it’s hard to do
that when a bear is biting you, right?
Client: Yeah, pretty much impossible.
Therapist: Right. It would be impossible, if not for our
emergency shutdown response. See, there’s this
big nerve in your body, called the vagus nerve,
and in these high-risk situations when fight or flight
seems futile, it actually immobilizes you. That’s
why we say “frozen with fear” or “paralyzed by
fright.” So your ancestor’s vagus nerve actually
paralyzes his muscles, so he literally can’t move,
can’t talk, can’t do anything. And at the same time,
it shuts off his feelings—makes him go numb, cuts
 off the pain, so he won’t scream and struggle. So
he’s lying there, paralyzed by fright, numb with
fear, speechless with terror. And if he’s lucky, the
bear sees he’s no longer a threat and leaves him
alone. And if the wounds aren’t too severe, he
survives.
Client: That makes sense.
Therapist: Yeah, so some of your symptoms—numbness,
apathy, no energy, zoning out, feelings of
hopelessness, wanting to just lie down and give up
—this is your nervous system in shutdown mode.
Again, we can link all symptoms of hypoarousal to this metaphor.
For example, in the case of dissociative states, the last line of dialogue
might change to this:
Therapist: So he’s trapped there, and it’s really horrible; so the
nervous system’s response is to spare him—it makes
him zone out, or split off, or gives him an out-of-body
experience. Now, he’s got some distance from what’s
happening to him, and again, this helps him survive.
This knowledge is hugely helpful for clients who froze during
traumatic events—especially sexual assault or abuse—who have blamed
themselves (or been shamed by others) for not resisting. And we can
flesh it out with the well-known examples of the deer frozen in the
headlights (freeze) or the mouse going limp in the jaws of the cat (flop).
Furthermore, if clients believe in evolution, we can add, “These basic
survival responses are ancient—they evolved many millions of years
ago, long before humans existed. They first appeared in fish, and we can
find them in all mammals, birds, and reptiles.” (But if clients don’t
believe in evolution, we might say, “So basically our nervous systems
are ‘designed’ to react like this—fight, flight, freeze, flop—because
these responses help us survive when we’re in grave danger. It’s the
same common design for all mammals, birds, and reptiles.”)
Following this, we can raise an important question: “So you may be
wondering, why does this keep happening?” To answer this, we discuss
the role of the amygdala.

The Amygdala: The Brain’s Threat

Detector
Although we commonly talk about the amygdala (singular), there
are actually two amygdalae, one on each side of the brain, in the
temporal lobes. These collections of nuclei (i.e., clusters of neurons that
cooperate to perform specific tasks) perform a number of different
functions but are best known for their role in processing fear.
Therapist: So there’s a part of your brain called the amygdala,
and it’s basically a threat detector. As soon as it
detects any kind of threat, it sets off an alarm, which
activates your fight or flight response, or, in some
cases, freeze or flop. And because of what you’ve
been through with XYZ (XYZ = specific details from the
client’s trauma history, such as the car crash, the war,
violent parents), your amygdala is now in a state of
constant red alert—it’s seeing threats everywhere, all
the time. Anything that even remotely reminds your
amygdala of XYZ will set off the alarm, including
thoughts, feelings, memories, people, places, objects,
situations, and activities. Quite often, we don’t even
know what’s triggering it—it’s set off by stuff outside of
conscious awareness.

Neuroplasticity
Many clients are doubtful as to whether therapy will work, so a
brief discussion about neuroplasticity can help:
Therapist: Have you heard of neuroplasticity?
Client: I’m not sure.
 Therapist: Well, it’s a big word, but the basic concept is that
our brain changes continually. There are over 80
billion neurons in the brain, and they’re all
interconnected, and we can sort of rewire them—
lay down new circuits. We can’t pull out the old
neural pathways—there’s no delete button in the
brain—but we can lay down new ones on top of
the old ones. And that’s what we’re aiming to do
here.
So if we did an MRI scan of your brain before you
start therapy and after you finish, we’d see
differences in those two scans. Those skills I
mentioned earlier—as you practice them, you rewire
your brain. For example, right behind here (therapist
taps a spot on their forehead in the mid-point
between their eyebrows) is the prefrontal cortex,
which is like the “mission control” center of the brain.
And you’re going to lay down new connections
between that part and your amygdala, the threat
detector—so you can adjust its settings, so the
alarms don’t keep going off.

Practical Tip
Be wary of simplistic ideas about “cause and effect” in the
neuroscience of trauma. We should remember that a trauma
reaction involves a whole human being and their ongoing
interaction with the environment via all of their biological
systems. For example, there are many other aspects of the
nervous system—aside from the vagus nerve—involved in
freeze responses, and the same goes for the amygdala’s role in
fear. So we should “hold lightly” any neurobiological explanation
for a trauma reaction, remembering it’s just one tiny piece of a
vast field of science in which many theories compete and
continually evolve.
 Acceptance and Self-Compassion
To facilitate defusion, acceptance, and self-compassion, ACT
explores the evolutionary origins of the mind: how it has evolved in such
a way that it naturally creates psychological suffering (Hayes et al.,
1999). And for the same purposes, ACT also explores the evolutionary
origins and adaptive functions of emotions, drawing upon affective
science (Tirch et al., 2014; Harris, 2015; Luoma & LeJeune, 2020). In
TFACT, two key points we make with our clients, and visit repeatedly,
are:

“These reactions are occurring through no fault of your own; they

are the product of millions of years of evolution.” (Or for
nonevolutionists: “This is the way your body has been designed.”)
“These are survival responses. This is your body, brain, and mind
trying to protect you, keep you safe.”

In later chapters, we’ll explore these themes repeatedly, and you’ll

see how we can reframe even intensely painful emotions, like shame,
and cognitive processes, such as suicidality, in terms of this protective
function. We might say, “The problem is not that there’s something
wrong with you—it’s just that your mind and your body are trying too
hard to protect you; they’re overly keen, doing these things to excess.”
Reframing clients’ symptoms in this way makes them easier to accept
and facilitates defusion from self-judgment.

EXTRA BIT Download Trauma-Focused ACT: The Extra Bits

from the “Free Resources” page on
http://www.ImLearningACT.com. In chapter three, you’ll find links
to several YouTube animations I’ve made about (a) the three
“parts” of the brain: reptilian, mammalian, and neocortex; (b) the
amygdala, hippocampus, thalamus, and prefrontal cortex; and
(c) the different meanings of “freeze” (there’s a third meaning I
didn’t have space to include here!).
Takeaway
The sympathetic nervous system (SNS) stirs and speeds us up
(hyperarousal), and the parasympathetic nervous system (PNS) stills and
slows us (hypoarousal). When we perceive a threat, the SNS activates
fight/flight mode—giving rise to fear and anger. But if fight/flight
appears futile, the PNS activates the freeze/flop mode—giving rise to
dissociation, apathy, and numbness.
A bit of psychoeducation about fight/flight and freeze/flop helps
clients to understand their symptoms, paving the way for acceptance,
defusion, and self-compassion.
 CHAPTER FOUR.

Keeping It Safe

For at least the first few sessions, most clients are highly anxious. This is
hardly surprising. It’s scary to make yourself vulnerable, allow yourself
to “be seen,” reveal things you’ve hidden from many others. It’s a huge
act of trust, especially if you’ve been hurt, manipulated, or betrayed in
other relationships. So it’s completely natural and expected that even
though we do all we can to make therapy a safe space, clients will at
times feel anxious, insecure, doubtful, distrusting, or fearful. So right
from the start, we validate and normalize these reactions as they occur;
and as therapy progresses, we help clients respond to them with
acceptance, defusion, and self-compassion.
In this chapter, we’ll explore what we can do to make therapy safer.
We’ll start with setting up our sessions, and then we’ll look at trauma-
sensitive mindfulness.

Setting Up Sessions
To enhance our clients’ sense of safety in session, we should carefully
consider the physical arrangement of the office, the therapeutic
relationship, the use of self-disclosure, informed consent, the “press
pause” technique, and making it easy for clients to say no.

Seating Arrangements
 Most therapists sit opposite or at an angle to their clients, with no
table in between. For many clients this is fine, but for some it’s
confronting and uncomfortable. Therefore, it’s a good idea to have at
least one large cushion available so the client can place it over their lap if
they want a protective barrier.
We can also ask, “How is this seating arrangement for you? We can
move the chairs if you prefer to sit a bit differently.” (I once had a client
who, for the first few sessions, sat as far away from me as she possibly
could, her chair backed against the wall. Over time, she gradually moved
closer.)

Therapeutic Relationship
ACT therapists adopt a Rogerian stance of authenticity, congruence,
and unconditional positive regard for the client. We take a mindful,
compassionate approach to our clients’ suffering, and we use ACT on
ourselves when our own reactions interfere with therapy. And we often
describe the therapeutic relationship as a form of teamwork:
Therapist: The idea is that you and I work together as a team, to
help you build the sort of life you want to live. So it’s
not going to be me analyzing you or telling you how to
live your life—it’s a collaboration; we work together.
And as we go, please do let me know if there’s
anything I’m saying or doing that’s getting in the way of
us being a strong team. I’m always willing to change
what I do, if it helps us work together better.

Therapist Self-Disclosure
ACT encourages (but does not demand) therapist self-disclosure for
the following purposes:
 A. To normalize and validate the client’s experience. For example:
“Yes. I do that kind of thing too. My mind really beats me up over
it” or “Yes, I get really anxious in those situations too.”
B. To strengthen rapport through empathy, compassion, and
authenticity. For example: “As you’re telling me this, I’m noticing
a lot of sadness showing up inside me. You can probably see my
eyes are tearing a bit. This deeply touches me.”
C. To model core ACT processes for the client. For example, to
model defusion: “I notice my mind telling me that you seem upset
with me. Is my mind way off base, or has it picked up on
something important?”
D. To address the therapeutic relationship. For example: “I could
have this wrong—so let me know if that’s the case. It’s just…I
don’t feel like we’re a strong team here. I feel like I’m pushing and
you’re resisting. What’s it like from where you’re sitting?”
E. To give safe, compassionate, and authentic feedback to the
client in the service of raising awareness of the effects of their
behavior in session.
So let’s suppose a client is complaining of disconnection and lack of
intimacy. At an appropriate moment, we might share, “Right now, I feel
really disconnected from you. You’re so caught up in all these thoughts,
it’s like you’ve disappeared from the room. I wonder if something like
this may be going on at times when you’re feeling that disconnection
with others?”
At a later point in the session, where the client is more engaged, we
might say, “Now I feel much more connected with you. It’s like you’re
fully back in the room, and you’re really engaging in what we’re doing
here. I feel like we’re a team now. Do you notice any difference?”
It goes without saying that therapist self-disclosure needs to be
wise, appropriate, compassionate, authentic, and always for the benefit of
the client—to help them progress toward their therapy goals. And we err
on the side of caution. For example, disclosures like A and B above are
probably fine in early sessions; but disclosures like D and E are more
confronting, so probably better left until later.
Even a light “sprinkle” of self-disclosure can be helpful. For
example: “Your mind is a lot like mine. The things your mind says to
you are so similar to the things my mind says to me!” In addition to
deepening rapport, this establishes a central ACT theme of “common
humanity”: we are all in the same boat; we all struggle and suffer; we all
have minds that naturally create suffering; life is difficult for each and
every one of us.

Informed Consent
Informed consent is good ethical practice and establishes trust. It
goes something like this:
Therapist: There’s a lot of difficult stuff going on for you, and
obviously we’ve only scratched the surface, so I
really want to hear more about it. But before we do
that, I’m wondering if we can take a few minutes to
discuss how we could work together, and what that
would involve.
Client: Sure.
Therapist: Great. So I mainly work from a model called ACT
—acceptance and commitment therapy. (playfully)
Yeah, I know it sounds a bit odd, but don’t let the
name put you off. It’s a science-based approach,
with over 3,000 published studies showing its
effectiveness.
Client: Wow!
Therapist: Yeah, so can I explain a bit about how it works—
and make sure you’re open to it?
Client: Sure.
Therapist: Great. So, there are a lot of difficult thoughts and
feelings and urges and memories you’re struggling
with—you’re suffering a lot—and there’s also a
whole bunch of really difficult situations you’re
dealing with. And when difficult stuff like this shows
up, for any of us, we have two main ways of
responding. One way is doing things that take us
toward a better life, more like the one we want; I
call those “towards moves.” The other way is doing
things that kind of take us away from the life we
want—you know, keep us stuck or hold us back or
make things worse—and I like to call those “away
moves.” (playfully) Sorry for the jargon.
Client: (smiling) That’s okay.
Therapist: And all day long, you and me, and everyone else
on the planet, we’re always doing this. One
moment, we’re doing those towards moves—doing
things that help us build the sort of life we want,
behave like the sort of person we want to be—and
the next moment, we’re doing away moves,
behaving unlike the sort of person we want to be,
doing things that keep us stuck or create new
problems.
Client: Yeah. That makes sense.
Therapist: So towards moves are basically things you’ll start
doing or do more of if therapy is successful. And
away moves are things you’ll stop doing or do less
of. Like, for example, you said that you’d like to
stop fighting with your partner all the time.
Client: Yeah, that’s right.
Therapist: So, that’s the basic idea. Now the problem is,
when difficult thoughts and feelings show up, we
tend to get hooked by them. Sorry, more jargon!
 What I mean by “hooked” is, they dominate us.
They take over. It’s like they hook us—and they
reel us in, and they jerk us around like a puppet on
a string, and they pull us into doing things that are
problematic, those away moves.
Client: Okay.
Therapist: So basically there are two main parts to ACT.
One part is learning new skills to handle all those
difficult thoughts and feelings—to take away their
power, so they can’t jerk you around and keep
pulling you into those away moves. And another
bit of jargon: we call those “unhooking skills.”
Client: That figures.
Therapist: The other part is to get better at doing towards
moves—which involves finding out what really
matters to you, who you care about, how you want
to treat yourself and others, and basically doing
things that make life better. So it’s a very active
approach. And the aim is for you to leave each
session with an action plan: something you’re
going to take away and practice or experiment
with, to help you deal with these issues.
Client: (anxiously) Hmmmm. That sounds a bit scary.
Therapist: That’s a completely natural reaction. Most people
find therapy a bit scary, because hey, you’re doing
something new, stepping out of your comfort zone.
And that is scary. But I guarantee you, we are
going to play it safe. We’ll go slow, and I’m here
with you every step of the way. And if you decide
that this approach isn’t for you, we can try
something else.
(Of course, informed consent also includes all the standard items:
confidentiality, expected number and frequency of sessions, terms of
payment, and so on. And if the client does not wish to do ACT, we can
either use a different model or refer to another practitioner.)

Press Pause
“Press pause” is a simple mindfulness intervention to raise
awareness of psychologically inflexible behaviors or reinforce
psychologically flexible ones. We often introduce it on the first session:
Therapist: Can I have permission to “press pause” from time to
time, so if I notice you saying or doing something that
looks like it might be helpful in terms of dealing with
your problems, I can just slow the session down and
get you to notice what you’re doing?
For example, I might ask you to just pause for
a moment, take a breath, check in, and notice
what you’re thinking or feeling—and then we’d
look at what you were just saying or doing
immediately before I pressed pause. That way,
you’ll be able to see more clearly what you’re
doing that’s helpful, and we can look at ways you
can use that outside of this room. Would that be
okay with you?
And can I also “press pause” if I see you doing
something that looks like it may be feeding into your
problems or making them worse, so we can address
it? And of course, this goes both ways—you can also
“press pause,” any time you like.

The Freedom to Say No

It goes without saying that we never coerce or push clients into
ACT processes. We want them to know they are in full control of what
they choose to do:
 Therapist: At times I will encourage you to try out new skills to
help you handle these difficult thoughts and feelings—
and that may pull you out of your comfort zone—so I
want to be clear that you never have to do them.
Please let me know if I ever suggest anything that
you’re not sure about, or you don’t see the point of, or
you don’t really want to do, and I will always take that
on board, straight away.
We expect that at times in therapy, clients will hesitate or express
reluctance to do things they find challenging or uncomfortable, such as
various experiential exercises or homework tasks, and it’s vitally
important that when this happens, we don’t cross that line from
encouragement to coercion (especially when working with complex
trauma, where many clients have been subjected to coercion in previous
relationships). So we check in frequently: “Are we okay to keep going
here?” “Would you like to slow down or take a break?” “My mind’s
telling me I’m being a bit pushy here; do I need to step back?”
And when doubts and fears about any aspect of therapy show up,
we never discount or dismiss them. We first normalize and validate such
reactions and look at the useful purpose they serve: “This is your mind
doing its job: trying to keep you safe, protect you from getting hurt.” We
can then return to the client’s therapy goals and compassionately and
respectfully explore those doubts and fears from the perspective of
workability: will acting on them help or hinder the client’s progress
toward the life they want to build? (This is a first gentle step in defusion;
we’ll explore this approach in depth in later chapters.)
It’s also useful to agree on a nonverbal safety signal the client can
use if they want us to stop, such as making the classic “time out” sign or
holding up a brightly colored card. “Press pause” works well for this
purpose: the client simply mimes pressing a button on a remote.

Trauma-Sensitive Mindfulness
People often think “mindfulness” is Buddhism, or meditation, or positive
thinking, or relaxation, or religion, or distraction, or a way to control
your feelings—but (at least, from an ACT perspective) it’s none of those
things. So what actually is it?

Defining Mindfulness
There are numerous definitions of mindfulness floating around; the
following one (Harris, 2018) combines key elements of many others:
“Mindfulness” refers to a set of psychological skills for effective
living, which all involve paying attention with flexibility,
openness, curiosity, and kindness.
This brief definition highlights three important points:

1. “Mindfulness” refers to a set of diverse skills.

2. The aim is to cultivate flexible attention: the ability to consciously
broaden, narrow, sustain, or shift our attention to different aspects
of our here-and-now experience.
3. Mindful attention is not cold or clinical; it has the qualities of
openness, curiosity, and kindness.

Alternative Terms to “Mindfulness”

Some clients report prior bad experiences with mindfulness: they
didn’t like it, they couldn’t do it, or it didn’t work. Upon inquiry, we
usually discover they are talking about formal mindfulness meditation—
as opposed to the flexible, trauma-sensitive mindfulness practices we
focus on in this book. And if we ask, “What were you hoping to get out
of it?” we usually find they were trying to get rid of unwanted thoughts
and feelings. So although it’s not “wrong” or “bad” to use the word
“mindfulness,” it’s often better to skip it, and instead use specific names
for the skills you teach: “unhooking,” “opening up,” “dropping anchor,”
“savoring,” “focusing,” “engaging,” “noticing,” and so on.
 We also need to be clear about the differences between mindfulness,
distraction, and relaxation. The word “distraction” comes from the Latin
distrahere, meaning “to draw away from.” Distraction techniques draw
attention away from unwanted cognitions, emotions, and memories in
order to reduce emotional pain. They are the very opposite of
mindfulness practices, where we deliberately turn toward unwanted
private experiences, with openness and curiosity.
Similarly, the primary aim of a relaxation technique is to control our
feelings: to get rid of tension and anxiety and replace it with calm and
relaxation. But with mindfulness, we do not attempt to control how we
feel; we open up and make room for difficult feelings and allow them to
be as they are.
We can include relaxation and distraction techniques in TFACT, but
we need to clearly distinguish them from mindfulness and specify when
they are appropriate (see chapter twenty-three) to prevent mixed
messages and confusion.

Mindfulness Meditation
In people who have experienced trauma, formal mindfulness
meditation can trigger adverse reactions, including anxiety, fear, panic,
and the reexperiencing of traumatic memories (Lindahl et al., 2017).
This isn’t surprising when we consider common elements of trauma-
related sequelae: social disengagement, physical immobility, and
problematic absorption in one’s inner world (rumination, worrying,
flashbacks, and so on). If clients with such issues attempt a formal
mindfulness meditation practice that involves sitting still (physical
immobility), staying silent with their eyes closed (social disengagement),
and focusing inward (absorption in their inner world), they are at risk of
fusion, dissociation, or reexperiencing trauma.
Trauma-sensitive mindfulness involves tailoring mindfulness
interventions to avoid such risks. So, at least for early sessions, it’s safer
to introduce practices that increase physical movement as opposed to
encouraging immobility; maintain or increase social engagement rather
than reducing it; and enable clients to acknowledge their thoughts and
feelings without getting lost in them. “Dropping anchor” exercises
(chapter eight) are especially useful for these purposes. Below I’ll cover
some important considerations regarding trauma-sensitive mindfulness.

BREATH AND BODY

Many mindfulness practices—especially formal mindfulness
meditations—include a central focus on breathing. This is useful for
most people, but a small number of clients, when focusing on the breath,
become anxious, dizzy, or lightheaded. For this reason, most of the
practices in this book do not include a central focus on the breath. It’s
not “wrong” or “bad” or “unsafe” to have such a focus—it’s just wise to
be cautious. So, when first introducing a breath-focused exercise, keep it
brief; check in with the client regularly; and if they respond adversely,
stop and explore their reaction.
If clients respond well to short breath-focused exercises, we can
then experiment with longer ones. But if not, there are hundreds of other
things to focus on: sounds in the room, what you can see, sensations of
stretching, and so on.
Many mindfulness practices focus on the body; this is often called
“somatic awareness,” “somatic mindfulness,” or “bodywork” (see
chapter twenty-two). It can be challenging to keep bodywork safe,
because often clients are striving hard to avoid particular parts of the
body, especially the chest and abdomen (because this is where anxiety
sensations are often most intense), areas associated with their trauma
history (e.g., parts involved in sexual abuse or parts that have been
disfigured through injury), and areas that are the focus of intense dislike
or loathing (as may occur in gender dysphoria or body dysmorphic
disorders). In such cases, we can initially help clients connect mindfully
with “safe zones” of the body—areas unlikely to trigger problematic
reactions. (For example, for most people, the hands and feet are safe
zones.) Then over time, through a process of graded exposure, we can
help them tune in to avoided areas.
 EVERYTHING IS AN EXPERIMENT
Every intervention is an experiment, and we never know for sure
what will happen. It’s often helpful to share this with our clients:
Therapist: I wonder if you’d be willing to try an experiment
here—an exercise I think could really help.
Client: Sure.
Therapist: Cool. I call it an experiment because I never
know for sure what’s going to happen. Most
people find it helpful, and that’s what I’m hoping for
—but I never really know. So let’s keep an open
mind and see what happens, okay?
This approach models honesty and openness, which contributes to
the therapeutic alliance. In addition, we take the pressure off: there is no
particular result that must be achieved. An experiment is an opportunity
to find out what works and what doesn’t. If the results are as hoped,
great. If not, we compassionately explore what happened, and work with
the client’s reaction (see chapter nineteen).

WHAT’S THE AIM?

The more unusual or uncomfortable the exercise, the clearer we
need to be about the purpose. What’s the point of this exercise? How’s it
going to help with their therapy goals? For example, depending on the
issue, we might explain the aim as:

to help you be present with your children, or focus on your work

to help you to open up and make room for difficult feelings and let
them flow through you without carrying you away
to unhook yourself from difficult thoughts so they don’t keep
pulling you into self-defeating behavior
to unhook yourself from memories that keep pulling you into the
past
 to take control of your body when it’s freezing up or shutting down
to disrupt worrying and ruminating

Without such clarity, many clients erroneously assume that

mindfulness practices are intended to get rid of unwanted thoughts and
feelings, to make them feel happy or relaxed. But in mindfulness
practices, we don’t try to control our thoughts and feelings; we allow
them to be as they are in this moment—whether pleasant or painful. Nor
do we aim to “clear our mind”; with openness and curiosity, we
acknowledge the thoughts that are present, and allow them to freely
come, stay, and go.
So when clients try to use these new skills to get rid of unwanted
thoughts and feelings, they’re not practicing mindfulness; they’re
practicing experiential avoidance. We know this has happened when they
say, “It’s not working.” When we ask what they mean by “not working,”
they reply, “I’m not feeling any better,” or “I’m still anxious,” or “The
thoughts are still there.” We then need to clarify the real aims of the
exercise. Four metaphors are useful for doing this quickly: Pushing
Away Paper (chapter two), Hands as Thoughts (chapter two), Dropping
Anchor (chapter eight), and the Struggle Switch metaphor (chapter
twelve).

INVITATIONS VERSUS DEMANDS

Every exercise is an invitation, never a demand. Notice the
difference between these instructions:

“I’d like you to push your feet gently into the floor, and notice what
that feels like.”
“I invite you to push your feet gently into the floor, and notice what
that feels like.”

Other phrases to consider include: “Could I suggest…?” “Would

you be open to…?” “Would you be willing to…?”
 Of course, there’s more to a genuine invitation than the words we
use; much relies on our authenticity, congruence, and compassion. Also,
the more clearly an exercise links to the client’s therapy goals, the more
inviting it is. For example: “I’ve got in mind an exercise we could do
right now that I think could really help with X (mentions one of the
client’s therapy goals). The aim of it is to Y (clearly states the aim).
Would you be willing to try it?”

BABY STEPS
Clients are often struggling with multiple problems. If they attempt
too many changes all at once, they can easily become overwhelmed,
resulting in increased anxiety, hopelessness, or giving up. However, if
they make no changes at all, they’ll remain stuck. So we need to help
clients find a balance, while also watching our own tendencies. If we
tend to go veeeery slowly, we may need to pick up the pace; but if we
habitually charge in full-speed ahead, we may need to slooooow down.
Basically, we individualize what we do for each client, carefully track
their responses, and adjust what we do accordingly.
We can use the language of “baby steps” and “domino effects” to
emphasize that small steps over time have significant effects, and a
positive change in one aspect of life often has secondary effects on
others. This same sensibility applies to all the exercises we do and skills
we teach. If we suspect that an intervention is likely to be too
demanding, too overwhelming, too challenging for a client, we scale it
down—make it smaller, simpler, easier, or even change it altogether. The
challenge for us all is to be flexible; if what we’re doing isn’t working,
we need to modify it.

Six Recommendations
Based on the above considerations, here are six recommendations to
make mindfulness exercises safer:
 1. Individualize exercises for each unique client; for example,
instead of focusing on the breath or body, you may initially focus
on sounds in the room or the view out the window.
2. Encourage clients to keep their eyes open and fixed on a spot,
rather than closed.
3. Clearly explain the purpose, linking it to the client’s therapy goals.
4. Promote social engagement by talking with your clients
throughout exercises: ask them what’s happening, what’s showing
up, and so on.
5. Encourage active movement during the exercises—especially
changing position, altering body posture, and stretching.
6. Make sure exercises are invitations, not demands—and repeatedly
check for willingness: Is the client okay to keep going? Do they
need a break?

Takeaway
Tailor what you do so it’s safe and appropriate for each unique client. Be
cautious about formal meditation practices that involve immobility,
silence, and closed eyes. Later, as clients’ psychological flexibility
increases, you can introduce such practices—but always with caution.
Clearly communicate the aims of your interventions. Set them up as
experiments, and be willing to modify or drop what you’re doing, as
need be. An explicit emphasis on safety and teamwork, along with
appropriate self-disclosure, helps build a strong therapeutic alliance.
 CHAPTER FIVE.

The Choice Point

Have you ever found yourself overwhelmed by a client’s initial

presentation? So many interconnected problems, you can’t figure out
where to start? If so, you may appreciate my personal favorite tool in
ACT: the “choice point” (Ciarrocchi et al., 2013; Harris, 2018). We can
bring in this simple but powerful tool at any stage of therapy to:

explain the ACT model

set goals
do functional analysis of a problematic behavior
provide a rationale for exposure
create a safety plan
set an agenda
and a whole lot more!

In this chapter, we’ll cover using the choice point to establish

therapy goals, introduce the ACT model, and conceptualize trauma.

Introducing the Choice Point

Before introducing the choice point to a client, we always listen
compassionately to the client’s narrative, validate their feelings, and
empathize with their difficulties. In the transcript below, all of this has
already happened.
The client, Helen, is a thirty-five-year-old flight attendant. Six
months earlier she was the victim of a vicious sexual assault. Her issues
include symptoms of hyperarousal (insomnia, impaired concentration,
palpitations, excessive sweating); reexperiencing the trauma (nightmares
and flashbacks); hypoarousal (“freezing up”), worrying, ruminating, and
self-judgment; conflict, tension, and avoidance of intimacy with her
husband, Mike; poor performance at work; social withdrawal; heavy
drinking; and staying up until the early hours of the morning, watching
TV.
Therapist: Is it okay if I draw a little diagram to summarize
what we’ve discussed and create a map for what
we do next?
Client: (nodding) Sure.
On a blank sheet of paper, the therapist draws two diverging arrows
and labels them “towards” and “away,” as below. (Reminder: to adapt
this for telehealth, see the PDF “ACT for Telehealth,” in Extra Bits,
chapter one). The client already knows the terms “towards moves,”
“away moves,” “hooked,” and “unhooking” from the informed consent
process—but the therapist briefly describes them again, for clarity.

Therapist: So this arrow is your away moves—things you

do that take you away from the life you want to
 build; things you’d like to stop doing or do less of.
And this arrow is your towards moves—things you
do that take you toward the life you want; things
you’ll start or do more of if therapy is successful.
Client: (nodding) Okay.
Therapist: And what I’m going to jot down here (points to
the blank space below the arrows) are some of the
main thoughts and feelings you’re struggling with,
and the difficult situations you’re facing.
Client: Alright.
Therapist: (writing while speaking) So you’ve got
flashbacks, painful memories, nightmares; feelings
of anger, anxiety, sadness, and guilt; physical
reactions such as freezing up, palpitations,
sweating, muscle tension; self-judgmental
thoughts like I’m unworthy, I’m weak, I’m damaged
goods. (continues writing while speaking) And
difficult situations like tension with Mike, falling
behind at work, difficulty sleeping.

At this point, a few clarifications. First a quick reminder: “away

moves” are values-incongruent, self-defeating behaviors; “towards
moves” are values-guided, effective behaviors; and both include overt
behaviors (physical actions) and covert behaviors (cognitive processes).
At the bottom of the choice point, we write down the main cognitions
and emotions the client is struggling with. This may include physical
pain, withdrawal symptoms from drugs, urges, memories, and
fight/flight or freeze/flop reactions. We also write down situations that
trigger away moves.

Practical Tip
If pushed for time, don’t write this information down; simply talk
about it while pointing to the diagram.

Mapping Out Away Moves

Next, the therapist explores Helen’s away moves:
Client: (looking at the paper, curious) Yeah, that’s about
right.
Therapist: And quite naturally, at times you get hooked by
all these thoughts and feelings. (Therapist writes
“hooked” alongside the away arrow.) They jerk you
around like a puppet on a string and pull you into
those away moves, taking you away from the life
you want.
Client: They sure do.
Therapist: So let’s jot down some of your away moves.
(Therapist writes while speaking, listing the “away
moves” down the side of the arrow). There’s
yelling at Mike, drinking too much, worrying…what
else?
 Client: I guess, avoiding meetings at work and falling
behind on everything…and avoiding my friends…
Therapist: Staying up all hours of the night?
Client: Yes. That too.
Therapist: And those freeze responses—when you lock up
and you can’t move?
Client: Yes, definitely. I hate that.
Therapist: Naturally. And remember, freezing up is
automatic, involuntary. You don’t choose it; your
vagus nerve does. So one of the aims here is to
learn new skills that can help, so if you do start
freezing up, you can catch it and override it—and
choose to do something different.

Before we return to our example of using the choice point with

Helen, here are four important points about away moves.

Point one: “Away” doesn’t mean away from pain. It means away from
values, or away from the life you want to build, or away from the sort of
person you want to be. “Hooked” is a synonym for inflexible
responding: fusion, experiential avoidance, or any combination thereof.
 So away moves may result from either fusion with or avoidance of
cognitions and emotions (and often, both).

Point two: The client always defines what is an away move—never the
therapist. Early in therapy, a client may see self-destructive behavior
(e.g., excessive drug or alcohol use) as a towards move. When this
happens, it’s useful to recall the transtheoretical “stages of change”
model (Prochaska & DiClemente, 1983). Here’s a brief recap:

Pre-Contemplation I don’t see this behavior as a problem

Contemplation I’m thinking about changing this behavior

Preparation I’m actively preparing to change this behavior

Action I’ve started doing the new behavior

Maintenance I’m continuing to do the new behavior

Relapse I’ve fallen back into the old behavior

If a client says a self-defeating or self-destructive behavior is a

towards move, that usually indicates “pre-contemplation”: they don’t yet
see it as a problem. We address this as follows:
First, we double-check: does the client understand the meaning of
towards moves? We might say, “Can I just check we’re using these terms
in the same way? Towards moves are things you’ll start doing or keep
doing if therapy is successful. Is this something you want to keep doing,
to the same extent?” If the client answers yes, we don’t want to debate it.
Clearly, they are in pre-contemplation, so if we start trying to persuade
them that this behavior is self-defeating, it could easily create tension
and strain the alliance. Instead, we want to find goals that strengthen the
alliance: behaviors that the client does want to change. So, we flag this
in our notes as an issue to address later—and for now, we write it down
from the client’s perspective, as a towards move. (Obviously there are
exceptions; for example, for a high-risk behavior such as suicidality,
we’d address that immediately.)
We then work with the client on changing behaviors that they do
see as problematic, using core ACT processes. This builds the alliance
and helps the client develop psychological flexibility.
Later in therapy, we revisit the issue. By then, it’s usually obvious
that this behavior is a barrier to the client’s other values-based goals, so
we ask, “When you first came to see me, you classed this as a towards
move. Do you still see it that way?” If for some reason, the client hasn’t
yet noticed the unworkability of their behavior, we raise their awareness
through gentle questioning: “So on the one hand, you want to be doing
things differently in your life, such as A, B, and C (values-based goals
and actions), but on the other hand, you keep doing X (the problematic
behavior). I’m wondering, do you see any conflict there?”

Point three: Emotions, urges, sensations, memories, and autonomic

responses always go at the bottom of the choice point. The towards and
away arrows only document behaviors: flexible and inflexible ways of
responding to the thoughts and feelings at the bottom.
Similarly, an individual thought (like I’m stupid or Nobody likes
me) always goes at the bottom of the choice point. However, cognitive
processes such as ruminating, worrying, or obsessing are covert
behaviors, so they go on the away arrow.

Point four: Any activity can be a towards move or an away move,

depending on the context. When I stay in bed and keep hitting the snooze
button primarily to avoid dealing with important tasks—I consider that
an away move. But on holiday, when I hit the snooze to enjoy the well-
earned pleasure of a long sleep-in—I consider that a towards move.
So if an activity takes us toward the life we want, then in that
context it’s a towards move; but if, in a different context, that same
activity takes us away from the life we want, then it’s an away move.
Thus, on my own choice point, beside the away arrow, I’d write
“sleeping in to avoid important tasks,” and by the towards arrow,
“sleeping in to enjoy my holiday.”
 With the choice point, we can take any DSM disorder, relationship
issue, or other clinical problem and rapidly “deconstruct it” into the same
four elements:

difficult situations (including work, relationship, financial, legal, or

medical problems)
difficult private experiences (including all types of cognition and
emotion)
inflexible responding to private experiences (“getting hooked”:
fusion or avoidance)
problematic overt or covert behaviors, resulting from fusion or
avoidance (away moves)

Unhooking Skills
Let’s return to our session with Helen.
Therapist: So here’s what basically going on. (Pointing to
the diagram while speaking) You’ve got these
challenging situations you’re dealing with, and
you’ve got lots of difficult thoughts and feelings
and memories showing up. And when you get
hooked by this difficult stuff inside you, you get
pulled into these away moves—drinking too much,
yelling at Mike, staying up late even when you’re
exhausted, and so on.
Client: (thoughtful) Yeah.
Therapist: So our aim here is to work together, as a team,
to help you turn this around and build a better life.
Client: (laughs sarcastically) Good luck with that!
Therapist: If I could listen in to your mind right now, what
would I hear it saying?
Client: This’ll never work.
Therapist: (playfully) Is that the polite version?
Client: (laughs) Yeah.
Therapist: (laughs) Thought so. Can I hear the unedited
version?
Client: Well, okay, you asked for it. This is fucking bullshit.
There’s no fucking way it’s going to work!
Therapist: (smiles) Excellent. That’s the way my mind
speaks too! And it’s completely natural to have
thoughts like that; almost all my clients do.
Client: Really?
Therapist: Absolutely. So your mind is saying this won’t
work—and even though it’s saying that, we can
still agree to work together as a team, right?
Client: Sure.
Therapist: And we can still agree on our aims here, even
though your mind says it won’t work?
Client: Yeah, I guess.
Therapist: So our aims are twofold. One is to develop some
unhooking skills, so when all these difficult
thoughts and feelings show up, you can unhook
from them (Draws a ring around all the thoughts
and feelings at the bottom of the diagram)—take
all the power out of them, take away their impact—
so they can’t jerk you around, or hold you back.
(Writes the word “Unhooked” alongside the
towards arrow.)
 Client: You think you can do that?
Therapist: I think you can do that. But I don’t expect your
mind to agree with me. Is it saying something right
now?
Client: Pretty much the same as before.
Therapist: Bullshit? Won’t work? (Client nods.) Yep, I expect
it’ll keep saying that, over and over.
Defusion involves responding flexibly to our thoughts: noticing
them with curiosity, seeing their true nature as constructions of words or
pictures, allowing them to freely come and stay and go, and using them
for guidance if helpful. Notice how the therapist is already instigating,
modeling, and reinforcing defusion through an open and curious attitude
toward the client’s difficult thoughts: noticing and naming them,
normalizing and validating them, and allowing them to be present
without challenging them.

Towards Moves
Now we’ll see how the therapist prompts Helen to identify towards
moves to add to the choice point.
Therapist: And the other aim of this approach is to get you
doing more of these towards moves—things that
help you build the life you want.
Client: I don’t quite understand…
Therapist: Well, basically towards moves are anything you’ll
start doing or do more of if therapy is successful.
For example, you mentioned you want to start
jogging again—so would that be taking you toward
the sort of life you want to build?
Client: Yes!
Therapist: Cool. I’ll jot that down. (writes it alongside the
towards arrow) Anything else?
Client: I’m not sure.
Therapist: Well, you said yelling at Mike is an away move,
so what would you like to do instead?
Client: I guess more patience. Staying calm instead of flying
off the handle.
Therapist: Okay, (writing it down) so talking calmly, being
patient. What about drinking?
Client: I like drinking!
Therapist: Don’t we all? The thing is, you said “drinking too
much” is an away move; so if therapy is
successful, what will your drinking habits look like?
Client: (heavy sigh) Honestly—I’m not sure. But less than
now.
Therapist: So for now I’ll just put “drinking moderately”?
Client: Okay.
Therapist: What about work?
Client: Yes, I’ll be going to meetings, and keeping up with
everything.
Therapist: You said it’s hard to focus at work—so just
wondering, should we add “focusing on my work”?
Client: Yes. That’d be a miracle!
Therapist: Friends?
Client: Yes, yes—seeing friends again.
Therapist: How about establishing good sleep routines?
Client: Yes, that sounds good.
Therapist: Okay, and I’m going to add one more thing here
—“learning unhooking skills.” I’m assuming that
would be a towards move too, learning how to
unhook from all this difficult stuff, and “unfreeze”
yourself?
Client: Yes, definitely.
Therapist: Okay, well, that’s a great start. We can add to
this later.
 Many clients need prompting to come up with towards moves, and
in chapter fifteen we cover several strategies for doing this. But
sometimes, despite our best efforts, a client will say, “I don’t know,” and
they may even become distressed about not knowing. If so, we
compassionately validate their feelings and normalize this lack of
knowledge: “That’s really quite common at this stage. Can we flag that
as something to explore later?” Then, for the time being, we focus on
unhooking skills—and leave towards moves until later, when we
formally explore values.

A Note About Action Versus Outcome

Many clients feel disempowered—and one way to empower them is
through helping them focus on what is within their control. Let’s
consider insomnia. Naturally, clients want to have a good night’s sleep—
but there is no guarantee they will achieve that outcome; it’s out of their
direct control. What is within their control is to implement the principles
of sleep hygiene (see chapter twenty-three). Therefore, in the session
with Helen, the therapist treats insomnia as a situation (in which sleeping
is difficult) and places it at the bottom of the choice point. In away
moves, the therapist writes “staying up late” (an ineffective behavioral
response to insomnia), and in towards moves, “healthy sleep routine” (an
effective behavioral response to insomnia). The therapist deliberately
does not write “sleeping well” in towards moves, because while that’s
the desired outcome, it is outside the client’s control.
The same applies to a medical condition or injury: cure or recovery
is outside of a person’s direct control. So we would frame this as a
problematic situation (e.g., “chronic pain syndrome,” “arm injury,”
“cancer”) and place it at the bottom of the choice point. Away moves
would be unworkable responses to that situation (e.g., heavy drinking,
avoiding medical advice), and towards moves would be effective ones
(e.g., following medical advice, practicing self-compassion, seeking
support).

Summarizing
One benefit of the choice point is how well it can summarize the client’s
situation and give us a helpful visual way to check in with them to see if
it seems on target.
Therapist: So, what I’ve drawn here is just bare bones—but
how is it as a snapshot of your main problems?
Client: It’s interesting. (looks thoughtful)
Therapist: I’m pleased to hear that. As a general plan for
working together…this seems okay?
Client: (nodding) Yes—it makes sense.
The client’s reaction above is quite common. The simple visual
representation often makes complex issues seem a lot simpler. (This is
partly because the therapist selectively focuses on key aspects of the
main issues. If the therapist exhaustively listed every single symptom
and problem, the process would take much longer and be
counterproductive.)
The exchange above involves “reframing”: looking at problems
from a new perspective to foster more flexible responses. Most clients
believe that their difficult private experiences are the problem and that
the aim of therapy is to get rid of them. But ACT offers a radically
different perspective: it’s not our emotions and cognitions that create our
problems; it’s fusing with or trying to avoid them, and the ineffective
behavior that results.
When we successfully introduce the new perspective that “getting
hooked” and doing “away moves” are the problems—and “unhooking
skills” and “towards moves” are the antidotes—this reframes both the
issue and the aims of therapy. (Of course, things don’t always go so
smoothly as above. At times, clients may have negative reactions, and
we’ll look at how to deal with that in chapter nineteen.)

A Simple Homework Task

After running through the above, we can now use the choice point for
homework:
Therapist: I’m wondering if between now and next session
you’d be willing to do a couple of things, to build
on what we’ve done today?
Client: Like what?
Therapist: Well, as you go through your day, see if you can
notice when you’re doing towards moves and
when you’re doing away moves. And when you do
towards moves, take a moment to slow down and
appreciate it, like “Hey, here I am doing something
that matters.” Notice what it’s like behaving like the
sort of person you want to be, doing stuff to build
the sort of life you want.
Client: Okay.
Therapist: Also, when we do away moves, we often don’t
realize it straight away. So the moment you realize
it, just pause for a moment, acknowledge it—and
 don’t beat yourself up over it, just see if you can
identify the thoughts and feelings that are hooking
you. Ask yourself, “What just hooked me?”
Client: Okay, I can do that.
We could flesh out this homework in various ways. We could give
the client a blank choice point and ask them to place it somewhere
prominent, as a memory aid. Or they could take a photo of the completed
choice point and use it as a reminder. Or they could keep a record of
towards and away moves, using the worksheets in Extra Bits. It’s a quick
way to help clients develop self-awareness: to notice when their behavior
is workable and when it isn’t; and to become more conscious of the
thoughts, feelings, and situations that trigger their problematic behaviors.

Fill in a Choice Point

Now it’s your turn to fill in a choice point for a current client. You can
download a blank diagram from Extra Bits, or draw one on a sheet of
paper. (Please do this, even if you never intend to use one with a
real client, because it will help you to understand the ACT model.
Allow about ten minutes.)

What’s Hooking Your Client?

Start at the bottom of the choice point. Use the entire bottom quarter
of the page to write down the following:
Situations: What difficult situations is the client struggling with? This
includes social, medical, occupational, financial, legal, domestic, and
relationship problems.
Thoughts and feelings: What difficult private experiences is the client
struggling with? This includes thoughts, feelings, memories, images,
urges, sensations, and physiological reactions.

Away Moves
Next write in the client’s away moves. What overt and covert
behaviors does the client see as problematic?

Towards Moves
Finally, write in towards moves. This section is usually the hardest
to complete. Clients are often good at describing the difficult
situations they face, the thoughts and feelings they struggle with,
and the problematic behaviors they are doing. But they often find
it hard to identify values, or value-congruent goals and actions. So
if you have little or nothing to write here, that’s golden information:
it highlights important areas for you to explore.
So how did you fare in this exercise? I hope you got a sense of how
to approach complex issues with TFACT. (Of course, if you’re not keen
on the choice point, you don’t have to use it; there are many alternatives
to any tool or technique. But if you do like it, there are many ways to
utilize it.)
Might clients perceive the choice point as too simplistic—especially
those with complex presentation, multiple issues, and comorbidity? Well,
it’s possible, of course; but it’s unlikely as long as we (a)
compassionately validate the client’s difficulties, and (b) clearly explain:
“Obviously there’s a lot more complexity to your issues than this. This
tool is a way to narrow the focus so we can start doing something
practical, right away.”

After the Choice Point, What Next?

After completing a choice point, we can give clients a choice: do they
want to focus first on towards moves or unhooking skills? If the former,
we move into values and committed action. If the latter, we move into
any of the four core mindfulness skills (defusion, acceptance, contact
with the present moment, self-as-context). Whichever option they
choose, our first task is to introduce a practical trauma-sensitive
mindfulness skill that they can immediately start using, to help them
both unhook from thoughts and feelings and act in line with their values.
(We’ll cover this in chapter eight.)

EXTRA BIT In chapter five of Trauma-Focused ACT: The Extra

Bits, you’ll find printable versions of the choice point, a
comparison of the choice point and the matrix (another popular
ACT tool), and a towards/away moves worksheet.

Takeaway
We can use the choice point for many purposes, including “quick and
dirty” case conceptualization, explaining the ACT model, establishing
therapy goals, setting an agenda for a session, and raising self-
awareness. It’s well worth taking the time to familiarize yourself with
this tool, because (as you’ll see) it has many other practical applications.
 CHAPTER SIX.

The Journey Ahead

So, here we are in the final chapter of part one, and the main question
now is: how can you best use the rest of the book? Basically, you have
two options. Option one is to work through each chapter in sequence, as
if following a protocol. Although TFACT is not a protocol, if you’re an
ACT newbie, then option one is wise. However, for those more
experienced in ACT, I recommend option two, which is to freely “pick
and choose”: take what’s useful from any chapter and apply it as needed
at any point in therapy. Before moving forward, though, let’s look at the
four flexible stages of TFACT—which coincide with parts two through
five of this book—and some common pitfalls to avoid.

Four Flexible Stages

I will now tentatively suggest four stages of therapy. Please hold them
loosely and use them flexibly.
Stage one, beginning therapy, usually takes two sessions: the intake
session (where we take a history, obtain informed consent, and establish
therapy goals) followed by the first session of active therapy.
Stages two, three, and four typically take several sessions. The
number varies depending on the extent and severity of the client’s
trauma history, the number of problems they have, how well they
respond to TFACT, how much they practice new skills—and of course,
how effectively we work.
 For most clients, it will take about eight to twelve sessions to cover
everything in this book—and sometimes, many more. But fortunately,
we don’t have to cover everything, because individual elements of
TFACT are helpful by themselves. For example, we could teach a client
a flexible trauma-sensitive mindfulness skill, and this could be of huge
benefit, even if we never see them again. Similarly, a session focused
solely on defusion, values, or self-compassion can be hugely beneficial
by itself, even without the rest of the model. Naturally, we want to cover
it all—but in the real world, that’s not always possible. This is why I’ve
included chapter thirty-three: “TFACT as a Brief Intervention.”
The table below summarizes these four flexible stages.

Stages of TFACT
• Taking a history
• Obtaining informed consent
Stage One: Beginning Therapy
• Establishing therapy goals
(One to two sessions)
• Psychoeducation on trauma
• Dropping anchor

Stage Two: Living in the Present • Defusion

(Four to six sessions) • Acceptance and self-compassion
• Clarifying values
• Committed action
• Breaking destructive patterns
• Working with the body
• Relaxation, sleep, and self-soothing
• Developing a flexible sense of self
 • Relationship skills
• Mindful appreciation

• “Inner child” work

Stage Three: Healing the Past • Grieving
(Two to four sessions) • Forgiving
• Exposure to traumatic memories

• Long-term goals
Stage Four: Building the Future • Maintenance and prevention plans
(Two to four sessions) • Exploring posttraumatic growth
• Ending therapy

These stages all overlap, and, aside from stage one, which we
always cover first, we can freely weave between them as desired. So, for
example, in stage two, if we want a more “bottom-up” approach
(working with the body, emotions, sensations) rather than a “top-down”
approach (working with cognitions), we can start with the strategies
listed in the lower half of that box, then later, bring in the ones in the
upper half. Similarly, for some clients, we may want to work first on
“healing the past,” in which case we’d focus on stage three strategies
initially, then introduce stage two later.

At What Stage Do We Begin Exposure to

Traumatic Memories?
In TFACT, unlike many other models, we tend to leave formal exposure
to traumatic memories until quite late in therapy. There are several
reasons for this. One, it’s often unnecessary. Many clients make
significant improvements in their life, health, and well-being without
ever needing to do such work. For example, in the WHO’s ACT protocol
for refugee camps, participants achieved positive outcomes without any
formal exposure to traumatic memories (Tol et al., 2020).
Two, if such work is necessary, it’s much easier to do when the
client already has skills in defusion, acceptance, dropping anchor, self-
as-context, and self-compassion.
And three, clients are usually more willing to do this challenging
work when it’s clearly linked to values-based goals. For example,
suppose a client wants to resume sexual intimacy with their partner but is
avoiding such activity because it triggers memories of sexual assault.
They may be more motivated later in therapy to undertake formal
exposure in the service of achieving this specific values-based goal—as
opposed to doing it earlier in therapy on the rationale that “it’s necessary
to recover from trauma.”

Three Common Pitfalls for Practitioners

As the saying goes, “forewarned is forearmed”—so I want to quickly
flag three common pitfalls for practitioners. Watch out for these traps;
they are sooooo easy to fall into.

1. Fusion with Diagnosis

A diagnostic label is helpful in a context where it gives access to
useful knowledge and effective treatment. But it’s not helpful in a
context where it increases stigma, fosters fusion with a sense of being
defective or inadequate, or leads to ineffective treatment. Problems can
occur when practitioners fuse with diagnoses and try to treat the DSM
disorder rather than the unique human being in front of them.
To avoid this trap, hold diagnostic labels lightly. Look at the issue
with ACT eyes; identify the fusion, avoidance, remoteness from values,
unworkable action, and loss of contact with the present moment. This
will open up many possibilities for intervention.
 2. Talking About ACT Instead of
Doing It
This is an incredibly common trap for ACT practitioners. We like
talking about ACT because there are so many interesting metaphors and
fascinating bits of psychoeducation. But just as we can’t learn to play
piano simply by talking about it, our clients won’t develop new ACT
skills simply through hearing metaphors or discussing how ACT
processes can be helpful. We need to actively help clients learn and
practice new ACT skills in session—noticing and naming their feelings,
mindfully scanning their bodies, practicing self-compassion, and so on—
and then encourage them to practice regularly at home. (I can usually tell
when therapists have been talking about ACT rather than doing it
because they say things like “We talked about acceptance” or “We did
the Pushing Away Paper metaphor,” or “I asked the client to reflect on
it.” It’s fine to briefly discuss what acceptance is and how it can help,
and illustrate it with a metaphor, but you then need to actively practice
acceptance skills in session.)

3. Practitioner Avoidance
Working with trauma is challenging. Sometimes practitioners
undermine the effectiveness of therapy by trying to avoid their own
uncomfortable thoughts and feelings. Without realizing it, they may
subtly discourage clients from discussing traumatic memories or suicidal
thoughts, or avoid challenging experiential exercises, or stay away from
exposure even though they know it’s warranted. Indeed, therapist
avoidance is usually a major factor in the previous pitfall: talking about
ACT instead of doing it; for most of us, it’s a lot more comfortable to
talk and chat and discuss than to do challenging experiential work
(especially exposure). So in order to be effective, we need to apply ACT
to ourselves: in line with our values as practitioners, commit to effective
action in session, making room for all the discomfort that arises.
What Measures Can We Use?
Most practitioners use formal measures to track clients’ progress. These
may include trauma-specific measures (e.g., PTSD Checklist [PCL-6]),
general measures of psychological distress (e.g., Kessler Psychological
Distress Scale [K6]), quality of life measures (e.g., General Health
Questionnaire [GHQ]), or ACT-specific measures (e.g.,
Multidimensional Experiential Avoidance Questionnaire [MEAQ-30];
Comprehensive Assessment of Acceptance and Commitment Processes
[CompACT]). There are no specific measures recommended for TFACT
—so please choose according to your personal preference.

Practical Tip
Completing measures eats up precious session time that could
arguably be better spent doing ACT, so consider asking clients
to fill them in before or after a session.

Takeaway
There’s no one “right” sequence for TFACT. The stages of therapy above
offer rough guidelines only; hold them loosely and apply them flexibly.
You’re going on a journey, and this book is like a guide to interesting
places worth exploring—rather than some strictly scheduled itinerary. So
take what’s useful, leave the rest, and adapt and modify everything to
suit your needs.
 PART TWO:

Beginning Therapy
 CHAPTER SEVEN.

Firm Foundations

There’s a lot to cover in the first session of therapy (the intake session):
taking a history, informed consent for TFACT, establishing therapy
goals, and psychoeducation about trauma. (If we don’t have time to do
all that, we can continue it in session two.) We covered informed consent
in chapter four, and psychoeducation on trauma in chapter five, so here
we’ll focus on the other items.

The Untold Story

“There is no greater agony than bearing an untold story inside you,”
wrote Maya Angelou. So we listen mindfully to our clients as they talk
about their hurts and their hopes, their loves and their losses. We create a
“sacred space” where they can be seen and heard and understood. We
validate and normalize their feelings; witness their stories and respond
with understanding and compassion. This is how the healing process
begins.
But this is just the start. Supportive, reflective, compassionate
listening is nowhere near enough to enable recovery from trauma. We
need to use the client’s narrative as a doorway to developing
psychological flexibility. So when we meet new clients and hear their
stories, we watch for anything that can help with this transition.
A large chunk of the intake session involves taking a history, and
how you do this will depend upon your previous training. Practitioners
trained in brief therapy take a short history, then promptly move into
active intervention in the intake session. Practitioners trained more
traditionally may spend an entire session or two gathering history before
beginning active intervention. One thing to keep in mind: we don’t need
to gather a client’s entire trauma history on intake. It’s fine to begin with
a snapshot of their main problems and an overview of relevant past
events. We can gather more information later, as it becomes relevant to a
specific issue we’re focusing on.

Do Clients Have to Talk About Their

Trauma?
No. Clients do not have to talk about their trauma. (Clients do not
have to do anything!) Indeed, if clients are pressured or coerced into
talking about their trauma, against their will, there’s a risk of
retraumatizing them. So while we like to know about the client’s past
and how it has impacted them, we don’t need to know every detail in
order to help them develop psychological flexibility. And we should not
push them to talk about it if they’re unwilling. Some clients may be
incapable of verbalizing their trauma until they have enough defusion,
acceptance, and mindful grounding skills to cope with the emotional
pain involved. Therefore, if clients are unwilling or unable to talk about
their trauma, we start building TFACT skills with whatever issues they
are willing to discuss.
When clients are able and willing to talk about their trauma, we go
slowly and cautiously, checking often for willingness: “Is it okay to keep
talking about this?” And we carefully observe their reactions while
encouraging them often to notice how they’re feeling or what they’re
thinking. And if, at any point, a client seems emotionally overwhelmed
or extremely fused, or a flashback occurs, or we see behavior suggestive
of dissociation—then we stop taking a history and move into active
intervention to help them cope with their reaction (see chapter eight).
Then, once the client is no longer overwhelmed but centered and able to
engage, we can continue with the history.
 Validate, Validate, Validate
There’s probably no need to say that we repeatedly validate and
normalize the client’s reactions—neurobiological, emotional, cognitive,
and behavioral—to the traumatic events they’ve experienced. We wish to
explicitly convey that these are normal reactions to traumatic events:
your mind, brain, and body working hard to keep you safe. (Sometimes,
overenthusiastic practitioners inadvertently invalidate their clients,
because they leap into core ACT skills without first doing this important
groundwork—forgetting that this is usually the first step in both defusion
and acceptance.) Likewise, many clients have done things to cope with
trauma that they now feel ashamed of or guilty about. So again, we want
to validate, validate, validate. We want to convey, “You did what you
needed to do to cope with what you were going through; it served a
useful purpose at that time.”

Checking In
While taking a history, we can from time to time ask the client to
“check in” and notice their feelings. For example, we might say, “Can I
press pause for a moment? I want to hear the rest of this, but I can’t help
noticing you look very upset. Can I ask, what are you feeling right
now?” We may follow up by asking, “Where are you feeling that in your
body?” and “What would you call this feeling?”
Doing this gives us valuable information. If a client says they feel
nothing, or they don’t know what they are feeling, this probably
indicates experiential avoidance and disconnection from their inner
world. On the other hand, suppose a client reports a tight chest and knots
in the stomach and labels this “anxiety”; that indicates some useful
ability in contacting the present moment and noticing and naming
emotions. From there, we may gauge their capacity for acceptance by
inviting the client to “sit with the feeling” and see if they can “open up
and make room for it.” If they can’t do this, so be it; but if they can,
that’s a good start for building acceptance skills.
 We may do something similar to assess a client’s ability to notice
their thoughts: “I’m curious—you’ve been sharing something very
personal here with me; I’m wondering, if I could listen in to your mind
right now, what would I hear it telling you about this?”

Strengths and Resources

As the client talks about their problems, we listen compassionately,
validate their difficulties, and look out for psychological rigidity. But this
is only half of the equation. We also want to discover skills, strengths,
and resources they can utilize. To do this we may ask:

Are there any areas of your life where things are okay or going
well?
What do you enjoy doing? Do you have any hobbies or interests?
Does anything you do give you a sense of meaning or purpose or a
connection with something bigger? Or a sense of pride or
achievement? Or a sense of being true to yourself?
Are there any times when difficult thoughts and feelings show up,
but you don’t let them hold you back from doing what really
matters to you?

Such questions tap into strengths and resources that we can draw
upon later, as a springboard to values and committed action.

Establishing Therapy Goals

It’s important to establish ACT-congruent therapy goals early on;
without them, we may find that the client expects something different
from what we are offering. However, this can be challenging. Clients
usually have a strong agenda of experiential avoidance; their main aim is
to “feel better” and get rid of unwanted cognitions, emotions, and
memories. These “emotional goals” will create huge problems if we
agree to them, so skillful reframing is required.

How to Reframe Emotional Goals

The following prompt (from Strosahl et al., 2012) is a good way to
elicit emotional goals:
Therapist: I’d like to get a sense of what you want from our
sessions. So could you please complete this sentence?
“I’ll know therapy is working for me when I…”
Almost always, clients will reply with emotional goals such as
“when I…stop feeling anxious, stop doubting myself, stop feeling
depressed, stop losing my temper, stop feeling so angry, stop being so
jittery, get rid of these memories and nightmares, stop feeling numb and
empty, stop taking things personally, stop being so narky, don’t have any
pain.” These goals all have the same agenda—experiential avoidance:
get rid of my unwanted cognitions, emotions, and sensations.
Sometimes this is stated as “when I…get over this, get my old self
back, be normal, build self-esteem, be like everyone else, put this behind
me, feel good about myself, get on with my life.” We would then ask,
“And how will you know you’ve achieved that?” The client’s next reply
then reveals the agenda: “I’d be feeling XYZ; I’d stop feeling ABC.”
Other emotional goals include “when I…am happy, feel good, feel
normal, have more confidence, feel calm, laugh again, feel joy, feel
relaxed, feel positive about life.” We may reply, “So you’re not feeling
the way you really want to. What kind of thoughts and feelings are you
having?”; this immediately reveals the unwanted thoughts and feelings.

EMOTIONAL GOALS ARE NORMAL!

All the goals listed above are normal. We’re all experientially
avoidant; we all want to feel good and avoid feeling bad. The problem is,
excessive experiential avoidance—and all the problems it fosters—plays
a central role in trauma-related disorders; so if we agree to such goals,
we reinforce it. Our clients are usually deeply distressed, overwhelmed,
or paralyzed by painful thoughts, feelings, and memories, and we want
to reduce their psychological suffering as fast as possible. But we don’t
do that by trying to avoid or get rid of them. So we need to reframe these
goals, to make them ACT-congruent—and do so without confrontation.
For example, we’d never say, “We don’t try to get rid of your difficult
thoughts or feelings in ACT. This approach isn’t about ‘feeling good.’”
(Especially when over 3,000 published studies show emotional pain will
reduce and clients will feel better.)

THE “CATCH-ALL” GOAL FOR ACT

Fortunately, there’s a “catch-all” ACT-congruent therapy goal that
applies to every client, a simple phrase that quickly reframes any goal
about emotional control: “Learning new skills to handle difficult
thoughts and feelings more effectively.” Once we know what difficult
private experiences the client wants to avoid, we can say:
Therapist: There are some very difficult thoughts, feelings, and
memories showing up for you, such as (mentions a
few). So one thing we can do is help you learn some
new skills to handle that stuff more effectively.
Here are two examples:
Client: I wouldn’t take things so personally. I wouldn’t get so
down about it when Dave teases me.
Therapist: Okay, so at the moment, when you take things
personally or get down about it, what kind of
thoughts and feelings show up for you? (elicits
answers) And what do you do when you get
hooked by those thoughts and feelings? (elicits
answers) So one thing we could do here is help
you learn how to unhook from those difficult
thoughts and feelings—take the power and impact
out of them so they don’t jerk you around. Would
that be useful?
 Client: I want more self-esteem.
Therapist: What do you mean by self-esteem?
Client: Oh you know—feeling good about myself.
Therapist: Okay, so thinking and feeling differently about
yourself; more positive; more upbeat?
Client: Yeah.
Therapist: So I’m guessing there are thoughts and feelings
showing up for you that you don’t want; what are
they? (elicits answers) And what do you do when
you get hooked by those thoughts and feelings?
(elicits answers) So one thing we could do here is
help you learn new skills to handle those difficult
thoughts and feelings—take their power away so
they can’t bring you down or hold you back. Does
that sound like it would be helpful?
On occasion a client may say that what they want most is to get rid
of their awful memories. In this case, the Horror Movie metaphor
(Harris, 2015) comes in handy.

The Horror Movie Metaphor

Therapist: We can’t simply eliminate memories—there’s no
delete button in the brain—but what we can do is
transform them. Suppose we compare these memories
to a terrifying horror movie—but obviously much, much
worse, because horror movies are fictional, whereas
this stuff really happened. So what happens is, at the
moment, when your memories appear, it’s like
watching a horror movie on a massive TV screen, all
by yourself, late at night, in a huge empty house, in the
middle of the countryside, during a thunderstorm. It’s
terrifying, overwhelming. But we can transform the way
 you respond to those memories, so that although it’s
the same horror movie, now it’s playing on the screen
of a smart phone, and that phone is in the corner of the
room, and it’s broad daylight, sun streaming in through
the windows, and you’re hanging out with the people
you love, eating delicious food, listening to great music,
doing things you really like to do. So would you be
interested in learning some skills that will help you to
do that?
All of the above reframing makes it easy to introduce new TFACT
skills, such as defusion, acceptance, and self-compassion. (And if using a
choice point for this process, we’d write unwanted thoughts and feelings
at the bottom, and we’d write “unhooking skills” on the towards arrow.)

THE ONE EXCEPTION: NUMBNESS

There is one exception to the “catch-all” goal mentioned above:
when clients are trying to get rid of emotional numbness. The client in
the transcript that follows was emotionally, physically, and sexually
abused throughout her childhood and is prone to dissociation, self-
harming, skin picking, and binge eating. She is successful in her career
as an artist, but very detached from her two young children. She feels
like she will never connect with them and is not even sure she wants to.
She says she’s never felt happy, never experienced a sense of
achievement, fulfilment, or love and affection. Here’s how we might
address this:
Client: I’m so sick of being like this. I just want to know what
it’s like to feel some laughter or joy or happiness or
love. Something!
Therapist: You’re not feeling any of that?
Client: I don’t feel anything anymore.
Therapist: You’re totally numb?
 Client: Pretty much. I mean, sometimes I get down or
cranky. But mostly, I just feel dead.
Therapist: That’s very common for people who’ve been
through what you have. (Therapist briefly explains
how emotional numbness results from “emergency
shutdown” mode, then continues…) So one useful
thing we can do here is help you learn some new
skills to tune into your body, so you can access the
full range of your feelings. And I say “the full
range,” because we can’t simply pick and choose
which feelings we have. It’s really about learning
how to tune into your body and feel all your
emotions. So another thing we can do here is
learn how to handle the difficult feelings when they
show up; how to take the impact out of them, so
they can’t jerk you around. And when you learn
how to connect with your own feelings, that will
help you to connect with your children.

How to Establish Overt Behavioral

Goals
In addition to the goals above, we want to establish overt behavioral
goals: “I’m wondering, if our work here is successful, what you will be
doing differently?” We may add:

What will you start or do more of?

What will you stop or do less of?
How will you treat yourself differently?
How will you treat others differently?
What places, events, or activities will you start or resume?
Who are the most important people in your life? What will you be
doing differently in those relationships?
 There are many other questions we could ask, including the classic
“magic wand” question:
Therapist: Suppose I have a magic wand here—a real one, real
magic—and I wave it right now…and suddenly all
these difficult thoughts and feelings you’ve been
struggling with lose all their impact. They no longer jerk
you around; they’re like water off a duck’s back. Then
what would you do differently?
In the transcript that follows, the therapist uses yet another popular
strategy: the seven-day documentary.

SESSION WITH SUE: OVERT

BEHAVIORAL GOALS
Sue is a forty-year-old woman, married with two young daughters.
A few years earlier she was the victim a vicious sexual assault, involving
repeated rape over several hours. She has many trauma-related
symptoms, including self-hatred, disgust and revulsion around her body,
high levels of anxiety, continual worrying, avoidance of sexual and
emotional intimacy with her husband, and repeated cutting on her thighs
and lower abdomen with a razor blade. She makes no eye contact at all
with the therapist, keeps her head downcast the whole time. She has
placed a large cushion across her lap, hiding her body from waist to
knee.
Therapist: I just want to get a little clearer about how your
life will be different, if our work here is successful.
So imagine we follow you around with a camera
crew now and we film you for a week—twenty-
four/seven, recording all the things you say and do
—and we make a documentary about it. And then
we do the same at some point in the future, after
therapy has finished, and make another
documentary. What kind of things would we see
you doing or hear you saying on that new
documentary?
Client: I could probably look at you.
Therapist: Okay, so we’d see more eye contact?
Client: Mmm, yep. Sometimes I can do that but…but yeah.
Therapist: Are there particular people that we’d see you
having more eye contact with?
Client: People like you, that know what happened.
Therapist: Is that the hardest, people that know?
Client: Yeah. Sometimes I can do it but with…you know,
people I just met. But not people who know.
Therapist: Okay. Would there be any other changes we’d
see on that video?
Client: Yeah, I probably wouldn’t um, just be so awkward.
Therapist: Okay. So…what would we see on the video?
Client: Um well, I’d probably just, I wouldn’t kind of just try
and hide all the time, have things cover me. (Client
indicates the cushion covering her thighs.)
Therapist: Like the cushion?
Client: Yeah.
Therapist: So if you were here, you’d be sitting without the
cushion?
Client: Yep. And I could maybe wear different clothes.
Therapist: What kind of clothes?
Client: Um, like…tank tops or boots or, you know, just kind
of a bit more modern.
Therapist: Okay. So you’d dress a bit more modern?
Client: Yeah.
Therapist: And what would we see or hear differently on the
documentary when you’re with your husband?
Client: Oh I’d probably talk to him a bit more, wouldn’t lie so
much.
Therapist: Okay. So you’d be more honest with him?
Client: Yeah, I wouldn’t hide so much.
Therapist: Got it. Are there any things in particular that you
wouldn’t be hiding?
Client: Um, oh like you know, like cutting and stuff.
Therapist: Okay. So would there be less cutting or it would
stop completely?
Client: I wouldn’t do it.
Therapist: So if the urge to cut shows up, what will you do
differently—instead of cutting yourself?
Client: Ummmm. (shakes head) I don’t know.
Therapist: No problem—that’s something we can look at
later. Are there any other things that we’d see on
the new documentary that would make us go
“Wow! Sue’s really made some progress there…
therapy really helped!”?
Client: (faintly chuckling) Oh I probably wouldn’t keep my
house so clean.
Therapist: So if you aren’t so busy cleaning, what will you
do with all that extra time?
Client: Play with the girls.
Therapist: Cool. So we’d see you playing with the girls
more. Anything else we’d see?
Client: Um, I wouldn’t have to worry about everything. I
could just let the girls go to their friends’ houses
without um, worrying about it.
Therapist: So on the documentary, what would we see or
hear that would show us “Wow! Sue’s really good
at unhooking from her worries”?
Client: They could just go.
Therapist: Just go to their friends’ houses?
Client: Yeah, there wouldn’t have to be so much planning
and I wouldn’t be sitting at home worried the whole
time.
Therapist: Right. So on the current video, when the girls are
at their friends’ and you’re at home, what would we
see or hear that we’d know, “Sue’s really been
hooked by her worries!”?
Client: Um…oh I’d be cleaning or showering or something.
Therapist: Okay. So in the new video, when the girls are off,
and you’ve unhooked from your worries, what
would we see you doing instead of showering or
cleaning?
Client: Um. Maybe reading a book or doing some exercise.
Therapist: Right. What kind of exercise would you do?
Client: Um, walking. Maybe ride…ride a bike.

A FEW NOTES
There are several things worth noting about the above transcript.
Note one: It seems long when written down, but in the actual session, it
only took a few minutes.

Note two: When the client revisited the emotional goal of “not being
worried,” the therapist reframed it to the (covert) behavioral goal of
“unhooking from worries.” There are many ways to use this reframe. For
example, if a client says, “I wouldn’t be feeling depressed,” we may say,
“So what would we see or hear on the new documentary that would
show us you had unhooked from all those depressing thoughts and
feelings?”

Note three: Questions like “What will you stop doing?” identify
behaviors that clients see as problematic but do not establish behavioral
goals. How so? Well, behavioral goals describe what you want to do (as
opposed to what you don’t want to do). So we need to follow up with
“What will you do instead?” For example, when Sue said she wouldn’t
cut any more, the therapist asked, “If the urge to cut shows up, what will
you do differently?” (If the client doesn’t know, we normalize and
validate that response, and flag it for later exploration.)

Note four: Some clients react negatively to the word “goals”; it triggers
shame or fear of failure. So consider avoiding using it in early sessions.
(In the transcript above, it is never mentioned.)

How to “Extract” Values from Goals

Our next step is to “extract” some values from beneath the client’s
overt behavioral goals. (Some practitioners clarify values first before
establishing goals; either way is fine. ) Usually, the values are right
beneath the surface. For example, in the transcript above, what values do
you think are likely underneath these goals: play with the kids, do less
planning, stop cutting, ride a bike, read a book, make eye contact, wear
modern clothes? Please generate some answers before reading on.
At this point, the therapist does not know what the client’s values
are, but it’s fine to make an educated guess:
 Therapist: So please tell me if I’ve got this right or wrong.
I’m getting the sense that as a mom, you really
want to be more playful and easygoing—is that
right?
Client: Yeah. And not so serious. I want to be more fun.
Therapist: Okay. So as a mother, being playful, easygoing,
and fun-loving. And with your husband, seems like
you want to be more open and honest?
Client: Yes.
Therapist: What about with other people? It seems like
you’re wanting to be more open, more authentic—
like, being the real you, instead of hiding away?
Client: Yeah. Yeah. And, you know—more um, like with my
husband, talking a bit more, and saying what I
really think.
In the above example, the values explicitly named are being playful,
easygoing, fun-loving, open, honest, authentic. But note: the therapist
never uses the word “values” because this term is commonly
misunderstood. Generally, it’s better to avoid this term until later in
therapy, when values become the central focus. Sometimes therapists
protest: “But isn’t this putting words into the client’s mouth?” To which I
reply, “Well, um, sort of, I guess…but not really.” What we are doing
here is helping clients put their values into words—often for the first
time in their life. If we get it wrong, they’ll usually correct us: “No, it’s
not that…” But if we’re right, they usually leap on it.
However, if you’re not comfortable with this approach, don’t do it;
wait until you start formal values clarification, as in chapter fifteen. Also
keep in mind that some clients—especially those with complex trauma—
have such an impoverished sense of self that the very idea of values is
utterly alien, and it may be a very slow process to clarify them (see the
“Impoverished Self” section, in chapter twenty-one). So if you’re not
getting anywhere—if the client repeats “I don’t know what I want” or “I
just want to feel better”—don’t turn it into a source of tension; approach
it as outlined below.

Barriers to Establishing Therapy

Goals
At times, it’s fairly easy to establish therapy goals; and at other
times, it’s fiendishly difficult. Let’s take a quick look at the most
common barriers, and how to overcome them.

I DON’T CARE ABOUT ANYTHING

Sometimes clients say they don’t care about anything at all.
However, we know they wouldn’t come to therapy unless they cared
about something. They at least care about reducing their own suffering—
and usually they also care about significant others. So we can highlight
the value of caring (for self or others) straight off the bat:
Client: I don’t care about anything.
Therapist: I hear you say that…and yet, here you are…you
turned up to the session. And that wasn’t easy,
right? You said yourself, it brought up a lot of
anxiety, you thought about canceling. And yet,
even with all those difficult thoughts and feelings,
you made it. So I’m wondering: what do you care
about enough that you actually attended?
Clients’ replies to the above question fall into one of two
categories: caring about self (e.g., I want to feel happy, I want my life
back, I’m just sick of feeling like this) or caring about others (e.g., I don’t
want to be a burden to my kids, I don’t want my wife to leave me). We
can then explore:
Therapist: So notice this. There’s a part of you that says, “I don’t
care about anything.” And there’s another part of you—
let’s call it “the caring part”—that got you here today,
 even though you felt anxious and wanted to cancel. So
if we can help you access that “caring part” a bit more,
it can be a useful resource for motivation.

HOPELESSNESS, NIHILISM, AND

SUICIDALITY
Sometimes clients are fused with nihilism or hopelessness: Life has
no purpose. Everything is pointless. Life is suffering and then you die.
There’s no point in doing anything because life is meaningless. There’s
no hope. Nothing works. I’m a lost cause. To work with this, see chapter
ten, the section headed “Therapy Session: Defusion from Doubt and
Hopelessness.” And for suicidal ideation, see chapter twenty-six.

INSIGHT AND UNDERSTANDING

Sometimes a client will say they are coming to therapy because “I
want to understand myself” or “I want to know why I’m like this.” We
may reply, “That’s a given. As we do this work you’ll get a lot of
understanding about your thoughts and feelings, and where they come
from, and why you have them, why you do what you do, what really
matters to you, and so on. But if that’s all you get from our work
together—you understand yourself, but nothing in your life changes,
things carry on exactly as they are today—would that be a good
outcome? Or are there some things you want to be different in your life?

NO GOALS AT ALL
No matter how skillful we get at establishing goals, at times, we
will hit a brick wall. The client will respond to every question with “I
don’t know” or “I’ve got no idea,” or shrug their shoulders and go silent,
or express that they don’t want anything at all. If this happens, we stop
questioning, and instead we compassionately explore the client’s
reaction. Are they fused with hopelessness? Overwhelmed by the
questions? Unable to imagine the future? We can address these barriers
as required, then return to the question.
 However, we want to avoid tension or conflict. So if a client
repeatedly says, “I don’t know,” we may reply, “I cans see that right
now, you really don’t know what you want. Actually, that’s quite
common. How about we put that on the agenda for later: make it part of
our work, going forward, to figure it out? The main thing is, right now
you’re hurting, you’re suffering. So let’s make that our main goal:
learning new skills to handle all those painful thoughts and feelings more
effectively.”

Takeaway
Reflective, compassionate listening as a client tells their story is of
fundamental importance. If clients are able and willing to talk, we find
out not only how they have suffered in the past, and the problems they
have in the present, but also their strengths and resources. We then set
goals for therapy—and, if possible, tease out values. This information
streamlines our sessions and ensures we are aligned with our clients;
without it, we easily get stuck. Establishing goals also fosters hope and
optimism; it gives clients a sense that things can improve, changes can
happen, a better life is possible.
 CHAPTER EIGHT.

Anchors Away

Welcome to the longest chapter in the book—and arguably the most

important, because the skill we cover applies to so many facets of
trauma. I call this skill “dropping anchor” (Harris, 2007): a collective
term for many mindfulness practices, all based on the same three-step
formula. Dropping anchor exercises are powerful first-line interventions
for emotion dysregulation, flashbacks, dissociation, hyperarousal,
hypoarousal, social disengagement, worrying, ruminating, obsessing,
panic attacks, extreme fusion, addictive behavior, self-harming,
suicidality, aggression…and a whole lot more.
Earlier, I mentioned an ACT protocol that I wrote (helped by many
others) for the World Health Organization for use in refugee camps.
Dropping anchor is the core mindfulness skill within that protocol;
participants learn it early in session one. It’s quick and easy to teach, and
people from many different countries—including Uganda, Sudan, Syria,
and Turkey—respond to it well. Of note, in the first published
randomized controlled trial of this protocol (Tol et al., 2020), there was
not a single adverse outcome; so it’s a good example of trauma-sensitive
mindfulness.
I’ve chunked this mega-chapter into five sections. First is
“Dropping Anchor: The Basics.” This covers the core components of
dropping anchor. Next comes “Working with Extremes of Arousal,”
which includes transcripts from two different therapy sessions. Sections
three and four, “Debriefing” and “Modifying,” look at how to debrief
these exercises and modify them for different issues. And section five,
“Homework,” is self-explanatory.

Dropping Anchor: The Basics

In the transcript below, you’ll see how dropping anchor gets its name
and how to introduce it to clients. This example focuses on anxiety, but
the same method applies for all emotions.
Therapist: So what you’re experiencing right now, I call this
an “emotional storm,” because you’ve got all these
thoughts whirling around inside your head, and all
these feelings whipping through your body. And
when an emotional storm gets hold of us, and
sweeps us away, there’s nothing effective we can
do; we can’t deal with the challenge or the problem
effectively.
Client: I know! That’s why I keep fucking up.
Therapist: Yeah, the storm just jerks you around all over the
place.
Client: Right!
Therapist: So would you be interested in learning a skill to
help you handle these emotional storms?
Client: Yeah, yeah. That would be good. That would be
great.
Therapist: Cool. Well, let’s talk about real storms for a
moment. Suppose you’re on a boat, sailing into
harbor, just as a huge storm blows up. You want to
drop anchor as fast as possible, right? Or your
boat will get swept out to sea.
Client: Right.
 Therapist: But dropping anchor doesn’t control the storm. It
just holds the boat steady—until the storm passes
in its own good time. And we’re going to do
something similar: learn how to “drop anchor”
when emotional storms blow up inside you.
Client: Okay.
Therapist: So this isn’t a way to control your feelings—just
like a real anchor doesn’t control storms. It’s a way
to hold yourself steady—even as that storm rages
inside you.
Client: (hesitant) Hmmm…soooo…what’s the aim?
Therapist: Well, actually there are three aims. One is to
take the impact out of all those difficult thoughts
and feelings, so they don’t jerk you around so
much. Two is to help you stay in control of your
actions—so you can control what you’re saying
and doing, to act more effectively. And three, it’s to
help you focus attention on what’s important.
Client: Okay. Makes sense.
Therapist: So okay to give it a go?
Client: Okay.
(But what if the client says they want to make the storm go away?
We’ll address that shortly.)

Practical Tip
Always specify that the boat is sailing into harbor (or a shallow
cove) when the storm blows up. Why? Because out at sea,
boats do not drop anchor during storms—and your nautically
minded clients will point that out.
Also, if a client is dissociating or overwhelmed, skip the
metaphor and go straight into active intervention. Say something
like “I can see you’re overwhelmed, and I want to help you
handle it. Can I take you through an exercise to help you?” If the
client can’t speak, say, “Nod your head, or tap your foot, if that’s
okay.” Later, once the client is centered, you can introduce the
metaphor during the debrief.

The ACE Formula: Acknowledge,

Connect, Engage
Using the three core processes of dropping anchor, we can create
literally hundreds of different exercises, improvise on the fly, modify
what we do based on the client’s responses, and vary the duration from
ten seconds to twenty or thirty minutes. The acronym “ACE”
summarizes these processes:
A—Acknowledge your inner world
C—Connect with your body
E—Engage in what you’re doing
Note: as alternatives, A can be “Acknowledge your thoughts and
feelings”; C can be “Come back into your body”; and E can be “Engage
in the world.”
In dropping anchor exercises, we usually run through three to five
“ACE cycles,” repeatedly acknowledging thoughts and feelings,
connecting with the body, and engaging in current activity. In this
section, I’ll describe each ACE component separately, and in the next
section, you’ll see how they flow into and overlap with each another
when we use them clinically.
 A—ACKNOWLEDGE YOUR INNER
WORLD
This involves mindfully noticing and naming your inner experience.
For example, when anxiety shows up, a client may notice threatening
images, scary thoughts, or unpleasant sensations such as a racing heart.
Or, when trying to break an addiction, a client may notice urges,
cravings, and withdrawal symptoms. The aim is to notice these private
experiences with openness and curiosity—and to nonjudgmentally name
them, with phrases like I’m having, Here is, or I’m noticing (e.g., I’m
having thoughts about being worthless, Here is a painful memory, or I’m
noticing numbness.)
This is relatively easy when clients are able to tell us what they are
thinking and feeling. For example, if we ask the client, “What are you
feeling right now?” and they report sadness, we may say:
Therapist: So acknowledge this emotion is present…say to
yourself, I’m noticing sadness.
The client may say such phrases aloud or silently, according to
personal choice. (In early sessions, most clients prefer the silent option.)
And if they can’t be specific about the cognitions and emotions present,
we can use nonspecific terms such as “pain,” “discomfort,” or “difficult
thoughts and feelings”:
Therapist: Acknowledge that right now there’s something difficult
and painful showing up…and if you can’t put it into
words, that’s okay…just say to yourself, Here’s
something painful.
As we cycle repeatedly through the ACE formula, this
nonjudgmental noticing and naming of inner experiences—without
trying to avoid or get rid of them—usually fosters both defusion and
acceptance. This may not happen on the first round, but it’s often starting
by the second or third.
As therapy progresses, we expand, lengthen, and deepen the
Acknowledge component in dropping anchor exercises. We spend more
time helping clients to connect with and explore the thoughts and
feelings present—to open up and make room for them, and respond with
self-compassion. Or we work more on the defusion elements, inviting
clients to observe the flow of their thoughts for a while, before moving
on to the next phase.
Troubleshooting: If Clients Can’t or Won’t Notice or Name
Sometimes clients are unable to name what they are noticing. This
is either because they’re so distressed or shut down that it’s impossible to
think, or because they don’t yet have the skill of naming their private
experiences. If we know or suspect clients will have such difficulties,
then for the first round of acknowledging, we omit the instructions about
naming, and instead say something like:
Therapist: Acknowledge that right now there’s something difficult
and painful showing up. And just get a sense of what it
is: whether it’s thoughts or feelings or a memory or
something happening in your body.
Then, as we get into the second cycle of ACE, we start encouraging
the client to name the experience. We ask, “What’s showing up now?
What kind of thoughts are going through your head? What kind of
feelings can you notice in your body?” If the client is now able to answer
us, we include this information in the next round of acknowledging:
Therapist: Okay, so again, acknowledge what’s going on inside
you…say to yourself, I’m noticing feelings of anxiety…
and thoughts about “doing it wrong.”
However, if the client still can’t tell us what they’re thinking or
feeling, we again say something like:
Therapist: Okay, so right now, it’s hard to put this into words,
and that’s oaky. Again, just acknowledge that there is
something difficult and painful showing up for you. And
again, just see if you can get a sense of what it is:
thoughts or feelings or a memory or something
happening in your body.
Another problem we may encounter is that sometimes clients don’t
want to acknowledge difficult thoughts and feelings. In this case, they
can acknowledge their desire to avoid them:
Therapist: So acknowledge there’s something going on in your
inner world that’s very difficult…and you don’t want to
look at it right now…so silently say to yourself, Here’s
something painful and I’m not ready to look at it.
What about clients who report not knowing what they are feeling?
Or those who say they are “not thinking anything”? This may be due to
experiential avoidance or skill deficits in noticing and naming their
cognitions and emotions (often both). In chapter ten (for cognitions) and
chapter thirteen (for emotions), we’ll cover the skills clients need to
overcome such barriers. In early sessions, before these skills are
developed, we may say, “Acknowledge there’s something
uncomfortable” or “Acknowledge an absence of thoughts and feelings.”

C—CONNECT WITH YOUR BODY

The idea here is to connect with (or come back into) the body. For
example, we may suggest that clients sit up straight, push their feet into
the floor, stretch their arms—and notice, with curiosity, the movements
involved and the changing physical sensations. And we tailor what we
do to suit each unique client. For example, if they have chronic pain
exacerbated by stretching their arms, we might instead suggest, “Ever so
slowly, shift your position in the chair to a more comfortable one…that’s
it…ever so slowly…and notice how you’re doing that…notice what
muscles you’re using…”
Connecting with the body can include stretching, walking, yoga, tai
chi, changing body posture, hugging oneself, tapping or stroking or
massaging various parts of the body, slowly shifting position in the chair,
mindful body scans, and so on. And if a client is avoidant of certain
aspects of the body (e.g., areas scarred or injured or involved in sexual
abuse, or parts disliked and unwanted in body dysmorphic disorder), we
initially focus on “safer” areas, unlikely to trigger negative reactions. For
example, we may encourage them to slowly wiggle their fingers, tap
their feet, or nod their head. (These are also good options for helping a
“frozen” client regain mobility; the extremities of hands, feet, and head
are usually the easiest body parts to get moving.)
It’s important that we always tailor this process to suit each unique
client. For example, early on in therapy, one of my clients, who is
transgender, did not want to connect with their hands or their feet
because this triggered unpleasant thoughts and feelings; they considered
their hands and feet to be “too big and masculine.” So instead, we
focused initially on shrugging their shoulders and stretching their neck.
As the client connects with their body, we encourage them to keep
acknowledging their difficult cognitions and emotions. (If we don’t do
this, dropping anchor will function as distraction.)
What About Mindful Breathing?
As mentioned in chapter four, early in therapy, let’s be cautious
about focusing on the breath. But if clients are okay with it (as most are),
it can facilitate connection with the body. For example:
Therapist: Notice the breath, flowing in and out of your nostrils…
Notice your rib cage, rising and falling, as the lungs
inflate and empty… And notice the gentle rise and fall
of your abdomen… And the subtle raising and lowering
of your shoulders…
With such exercises, we can increase connection with the body by
inviting the client to place one hand on their chest, the other on their
abdomen:
Therapist: Notice your hand rising as your chest expands…and
falling as the breath flows out again… And notice your
other hand…gently rising and falling…as your
abdomen gently moves in and out…
Another option is to close and open both hands, in time with
breathing:
Therapist: As you breathe in, curl your hands into gentle fists…
and as you breathe out, let them open…
The next phase of dropping anchor is to Engage.
 E—ENGAGE IN WHAT YOU’RE DOING
After acknowledging thoughts and feelings, and connecting with
the body, the aim is to refocus and engage in current activity. We may
ask clients to notice where they are, what they are doing, and what they
can see, hear, touch, taste, and smell. (If someone protests, “I can’t
notice all that!” we modify the exercise to notice only one or two things
at a time.) We can really be creative here, drawing attention to anything
external, from sounds of distant traffic to cracks in the ceiling.
Therapist: And now taking a moment to really notice where you
are and what you are doing…looking around the room,
and noticing what you can see…on the floor…and on
the ceiling…and to either side of you…noticing the
flowers in the vase upon the table…the color of the
leaves…and the way the light reflects off the glass…
and noticing all the different sounds you can hear…
sounds coming from you…and from me…and from the
air conditioner…and the traffic outside… And breathing
in the air, noticing what that’s like…and noticing you
and me here, doing this activity…
We can, if desired, ask clients to describe aloud what they are
noticing; this is especially useful when they are finding it hard to be
present. (However, some people don’t like doing this—so always make it
optional.) In this phase, we continue to acknowledge thoughts and
feelings (again, to prevent this from functioning as distraction). For
example, after a client has engaged with the world around them, we
might say, “So notice, there are still difficult thoughts and feelings
showing up…there’s your body around those feelings—can you move or
stretch a little, notice it moving?…and notice, there’s a whole room
around you…and notice you and me here, working together as a team—
doing this strange exercise.”
When we ask the client to “notice you and me,” this utilizes the
therapeutic relationship as an anchor in the here and now. At times, we
may push this further, asking things like “Can you notice the color of my
shoes? The color of my shirt? My position in the chair? Can you notice
how I’m stretching my arms, just like you?”
 Practical Tip
It’s not a good idea to tell clients “You are safe,” because this
may be interpreted as “You are safe; therefore you should not
be feeling anxious, fearful, or insecure.” While dropping anchor
often helps clients access a sense of safety and security, we
want to clearly communicate that anxiety and insecurity are
normal; it makes perfect sense that the client would have such
feelings, given what they’ve been through.

We then repeat the ACE cycle, at least another two or three times,
but each time around we go more slowly, with longer pauses and less
instruction (so clients learn how to do it for themselves). At the end of
the first cycle, we say:
Therapist: Okay, so that’s the basic drill. Can we run
through it again? Great. And this time, I’ll do less
talking. So let’s start with the A. Take a moment to
notice your inner world…acknowledging your
thoughts…acknowledging your feelings…and are
they the same as before or different?
Client: Pretty much the same.
Therapist: Feelings of anxiety?
Client: Yeah.
Therapist: And the same scary thoughts?
Client: Yeah.
Therapist: Okay. So acknowledging that those thoughts and
feelings are present…and allowing them to be
there…and silently saying to yourself, I’m noticing
anxiety…and at the same time connecting with
your body…straightening up your back…pushing
your feet into the floor…
 There is no need to follow a script for these exercises. You can if
you wish—there’s one in Extra Bits—but it’s better (and more
enjoyable) to improvise. Give your voice a kind, calm quality, and go
slowly, pausing for five to ten seconds (or longer) between instructions.
And be sure to model all the actions for your client—for example, press
your own feet down and stretch your own arms outward, as you invite
the client to do likewise. This makes clients feel less self-conscious and
builds that sense of teamwork. Also feel free to vary the order of the
components; for example, with some clients, it works better to connect
with the body first.
We typically cycle through this process—acknowledging inner
experience, connecting with the body, and engaging in the world—for at
least three or four minutes, until the aims of the exercise are achieved.
This raises an important question…

What Are the Aims of Dropping

Anchor?
Dropping anchor exercises have many different aims. The most common
ones are:
A. to gain more control over physical actions—so we can act
effectively when difficult thoughts and feelings are present. This is
a powerful antidote to the physical immobility (“freezing up”)
associated with hypoarousal, flashbacks, intense shame or
hopelessness, and dissociation.
 B. to reduce the impact and influence of our cognitions and
emotions. Consciously noticing and naming them reduces their
influence over our behavior (whereas when we’re on automatic
pilot, they easily hook us and pull us into away moves). Indeed, we
can think of dropping anchor exercises as a form of ACT-
congruent “emotion regulation.” We are not trying to avoid, get rid
of, or control emotions, but we are reducing their impact through
responding mindfully. And as the impact lessens, it becomes easier
to stay in the present moment and choose effective actions over
self-defeating ones.
C. to interrupt problematic covert behaviors, such as worrying,
ruminating, and obsessing.
D. to interrupt problematic overt behaviors, such as aggression,
social withdrawal, self-harming, or substance abuse.
E. to help us “wake up,” focus on and engage in what we are
doing: the antidote to disengagement, distractibility, and
dissociation.
We need to be clear in our own mind what the aims are for each
unique client in each specific situation—and clearly communicate this. If
not, confusion is likely. So it’s worth taking the time to practice your
spiels. For example, suppose a client says, “I don’t get it. Why keep
coming back to the body?” You can reply with a quick user-friendly
version of points A and C above: “Well, it’s to help gain control of your
physical actions, so you don’t get jerked around by your thoughts and
feelings. And it’s also to get you out of your head.” Likewise, if a client
asks, “What’s the point of acknowledging?” you want a simple, snappy
version of point B: “Well, it’s the first step in unhooking from difficult
thoughts and feelings. Learning to notice and name them takes some of
their power away.” (If the client wants to know more, you could explain
how this helps with defusion or acceptance, using the rationales in
chapters ten and thirteen.)

Practical Tip
 If clients are willing to have and open to their emotions, and able
to remain engaged in the session, all we need do is hold a safe
space for them, where they can “be with their feelings.” But if
clients are starting to dissociate, avoiding or struggling with their
emotions, fusing with helplessness or hopelessness, or so
overwhelmed by their feelings that they can’t engage in the
session—then dropping anchor is called for.

Dropping Anchor Versus Distraction

I hate to be repetitive, but there’s so much misunderstanding around
this, I’m going to say it again: when dropping anchor, there’s no
intention to distract. Distraction is a form of experiential avoidance. And
given that our clients are already high in experiential avoidance, we
don’t want to reinforce it. (Besides, most clients already have many ways
of distracting themselves, so we want to give them something new.)
The aim with dropping anchor is to learn a new way of responding
to thoughts and feelings, one that is radically different from avoidance.
The aim is to notice, name, and allow these thoughts and feelings; make
room for them; let them freely come, stay, and go in their own good
time.
On that note, there’s a big difference between most grounding
techniques and dropping anchor. In most models, grounding functions as
distraction. For example, popular grounding techniques include holding
an ice cube and noticing it melt, counting backward from a hundred in
sevens, snapping an elastic band around your wrist, silently reciting a
poem or mantra or the times tables, and so on. The usual aim of these
practices is to distract from difficult thoughts and feelings, to reduce
emotional distress.
Some popular grounding exercises at first glance appear to involve
mindfulness: using your five senses to notice the world around you,
slowly stretching your body, savoring a drink, going for a walk and
taking in the sights and the sounds, and so on. But again, the primary
aim of these practices is usually to reduce emotional pain. Typically, they
use the C or the E of ACE, but not the A; so without that ongoing
acknowledgment of inner experience, they function as distraction.

Does Dropping Anchor Reduce Pain?

If a client drops anchor while in intense emotional pain, it’s unlikely
the pain will disappear. However, usually it loses its impact; its power
“drains away.” And within a few minutes (sometimes much faster),
many clients report a sense of calmness, even as the storm continues. At
other times, emotional pain will drop rapidly—and as mentioned earlier,
clients may misinterpret this as the main purpose and then start misusing
this practice to control how they feel. If so, they soon complain, “It’s not
working” or “It’s lost its effectiveness,” which we’d address as in
chapter four (in the section headed “What’s the Aim?”).

Practical Tip
Any type of mindfulness exercise may, on occasion, increase
pain because clients suddenly become aware of sensations,
thoughts, or emotions they usually suppress or distract
themselves from. Dropping anchor is no exception. If this ever
happens, we segue into work on undermining experiential
avoidance (chapter twelve).

Working with Extremes of Arousal

The “window of tolerance” is a popular concept in trauma therapy; it
refers to the zone of arousal in which a person can function most
effectively. But in TFACT, we prefer to talk about a “window of
flexibility,” which we help clients to widen as their state of arousal
varies. In other words, we develop clients’ ability to respond flexibly—
to be present, acknowledge inner experience, and take effective control
of physical actions—during various degrees of autonomic arousal. If at
any point clients are “outside their window of flexibility” (i.e., unable to
respond flexibly to their emotions, cognitions, and physiological
reactions), we quickly help them “get back into the window” through
dropping anchor. The transcripts that follow illustrate this process.

Session with Lottie: Hypoarousal

Lottie is a forty-two-year-old nurse, a single mother of two, with
complex trauma. Her history includes repeated childhood sexual abuse
and domestic violence and sexual assault in adulthood. The scene in the
transcript below takes place about halfway through the intake session.
While talking about abuse by her father, Lottie has become overwhelmed
and unable to speak. She is shaking and trembling, face pale, tears in her
eyes. The therapist has asked her what is happening, but Lottie is either
unwilling or unable to reply. The therapist guesses she is either
completely overwhelmed by her emotions to the point of shutdown or
she is dissociating (or both).
As you read this transcript (and the next), please imagine yourself
saying and doing something similar with your own client. (And if you’re
willing, try reading the words aloud to get a deeper experience.)
Therapist: Lottie, I can see you’re struggling with something very
difficult right now, and you can’t speak. If you can hear
me, please nod your head. (Lottie does not respond.)
Lottie, please nod your head, even a little bit, if you can
hear me. (Lottie nods her head slightly.) Great. I want
to help you deal with whatever this is that you’re
struggling with, so I’d like to take you through a little
exercise to help you handle it. Just nod your head if
that’s okay. (Lottie nods.) Okay, great.
When clients can’t speak, we can ask them to nod their head, tap
one foot, or move one finger to indicate they can hear us. Once we’ve
established such communication, we can follow the ACE formula. We
could also, if desired, try to ascertain what is showing up for the client:
“Nod your head if you’re feeling some strong emotions,” “Nod your
head if there’s a painful memory,” and so on.
Therapist: (Acknowledging the inner world) Okay. So you
don’t have to speak, but just acknowledge to
yourself that there’s something very difficult you’re
struggling with right now…and take a moment to
acknowledge whatever it is that’s showing up…
whether it’s thoughts, feelings, memories…
Therapist: (Connecting with the body) And these thoughts
or feelings or memories are happening inside your
physical body, which seems to be all locked up.
Just nod if your body seems kind of frozen or
locked. (Client nods.) Okay, so let’s see if you can
unlock it a bit, get it moving. Can you tap one of
your feet? (Client taps right foot.) Great. Can you
tap the other one? (Client taps left foot.) Great,
see if you can tap them both together, like this.
(Therapist taps both feet up and down. Client does
the same.) Very good.
Therapist: Now can you wiggle the fingers on one hand?
(Client wiggles fingers on right hand.) And can you
wiggle the fingers on the other hand? (Client does
so.) And can you wiggle them all together, like
this? (Therapist wiggles all fingers; client copies.)
That’s great. And is it okay if we keep going with
this? (Client nods.) Okay, so see if you can loosen
up your head a bit…try turning from side to side…
(Client does so.)…that’s great…and can you
maybe shrug your shoulders a little… (Client does
so.)…excellent…
Therapist: (Acknowledging, Connecting) So notice there are
difficult thoughts or feelings or memories showing
up, and you have a body around them, which you
can move. Can we keep going with this? (Client
 nods.) Okay, see if you can move your legs a little,
jostle them up and down, like this. (Therapist
demonstrates, client copies.) Great. And now see
if you can push your feet down really hard, into the
floor…and notice how that lifts you up off the chair
a bit…and now ease off. (Therapist demonstrates,
client copies.) Excellent. And see if you can maybe
gently shrug your shoulders…and can you stretch
your arms out a little? (Therapist demonstrates,
client copies.) That’s good. So there are difficult
feelings and memories showing up, and your body
is around them, and you can move your body, you
have some control over it…
Therapist: (Connecting, Engaging) And see if you can keep
moving, I know it’s a bit odd, but it’s important to
unlock your body…you can copy me if you like, or
just move it how you want (Therapist and client
continue to move their bodies—tapping feet,
stretching arms, shrugging shoulders, etc.)…and
at the same time, see if you can also get a sense
of the room around you…notice three or four
things you can see directly in front of you…and
can you turn your head to one side, and notice
what you see there…that’s great…and can you
look up, see what’s on the ceiling…and down on
the floor…and also notice what you can hear…my
voice…and the traffic outside…the air
conditioner…so notice where you are…and notice
you and me here, doing this weird exercise…
Therapist: (Acknowledging, Connecting, Engaging) So
there’s a lot of painful stuff showing up inside you,
and around that stuff is your body, which you can
move—is it okay to keep moving? (Client and
therapist keep moving their bodies—stretching,
shrugging, tapping feet, etc.)…and around your
 body, there’s this room here, and you and me,
working together…
Therapist: And I’m wondering, are you able to talk yet,
about what’s going on? (Client shakes her head.)
Okay, you don’t have to. Is it getting any easier to
tune in to what I’m saying? (Client nods.) And
you’re starting to unlock a bit in your body? (Client
nods.) Is it okay to run through this again? (Client
nods.)
The therapist runs through the ACE cycle another three times,
varying the instructions. This takes about five minutes. By the end of the
fourth cycle, the client is present and able to talk, and the therapist
debriefs the exercise. We’ll cover debriefing shortly; first let’s look at
another transcript.

Session with Jeff: Hyperarousal

Jeff is a thirty-year-old male with PTSD, following a car accident in
which he was the front passenger. His best friend, who was driving, was
instantly killed. This exchange is early in the second session. Jeff is
struggling with intense anxiety: pounding heart, sweaty hands, churning
stomach, tightness in his chest, lots of thoughts about the accident and
about whether he is going crazy. The therapist has already introduced the
dropping anchor metaphor and explained the aims of the exercise:
Therapist: So, just to be clear, this isn’t a way to control
your feelings—just like a real anchor doesn’t
control storms. It’s a way to hold yourself steady,
even as the storm rages inside you.
Client: Okay, let’s try it.
Therapist: Okay, so there’s a simple formula for doing this,
which you can remember as A-C-E, “ace.” The A
of “ace” is for “acknowledge your thoughts and
feelings.” So the idea is to acknowledge what kind
 of thoughts and feelings are showing up for you.
You want to kind of look inside yourself, as if
you’re a curious scientist trying to observe what’s
going on in there. So let’s start with your mind;
what kind of thoughts are going through your head
right now?
Client: Same as before—Dave’s dead and it’s my fault, and
am I going crazy?
Therapist: Okay, so acknowledge, and say to yourself, “I’m
noticing scary thoughts.”
Client: Say it aloud?
Therapist: Aloud or silently—whichever you prefer.
Client: (a bit unsure) I’m noticing scary thoughts.
Therapist: Okay. And you also acknowledge what’s
happening in your body. What’s it like in your chest
there?
Client: It’s really tight.
Therapist: Okay. And your stomach?
Client: Just like before—it’s all churning.
Therapist: Throat?
Client: Yeah, there’s um—there’s a kind of lump.
Therapist: And your hands?
Client: They’re um—yeah, they’re sweaty.
Therapist: Okay. So there are quite a few different feelings
in there. So say to yourself—silently or aloud,
doesn’t matter—say, “I’m noticing feelings of
anxiety.”
Client: I’m noticing feelings of anxiety.
Therapist: Now the C of “ace” is for “connect with your
body.” So you’ve got all these anxious thoughts
and feelings in here, and all of that is inside your
physical body. So see if you can keep
acknowledging the anxiety, and at the same time
connect with your body. Just copy me. Try pushing
your feet down into the floor. (Therapist models
this action, and client copies.)… That’s it. Feel the
ground beneath you.
Now try straightening your spine (Therapist
models this while talking. Client copies.)… That’s
it. And notice how you naturally sit forward as your
spine straightens. And notice your thighs resting
on the chair beneath you; and keep those feet on
the floor.
Now slowly shrug your shoulders together, roll
them around a bit, and loosen up your neck a bit.
(Therapist models these actions while talking.
Client copies.) That’s it.
Now how about stretching out your arms?
(Therapist stretches out and client copies.) Yeah,
that’s it. Feel your arms moving, notice your upper
back stretching.
And take a moment to acknowledge there’s a
lot of anxiety here…and it’s challenging and it’s
difficult… And again, say to yourself, out loud or
silently, “Here’s anxiety.” (Client silently nods his
head, to indicate he is doing this.) So notice—
there are anxious thoughts and feelings here, and
there’s also a body around all that stuff—holding it,
containing it all. And you can move and control it.
So straighten your back again, and notice your
whole body now…your hands, feet, arms, legs…
that’s it. (Therapist models these actions. Client
copies.) Gently moving…and really noticing what
 those movements feel like… And having another
stretch, a really big one… And noticing those
muscles stretching…and how are you doing there?
Client: I’m okay.
Therapist: Excellent. So now the E of “ace” is for “engage in
what you’re doing.” In other words, notice where
you are, and focus on what you’re doing. So take
look around the room—up, down, and side to
side… (therapist looks around the room) and
notice five things that you can see… And also
notice three or four things you can hear…sounds
coming from me or you or the room around you…
And also notice you and me here, working
together, as a team.
So notice, there is anxiety here right now—
scary thoughts in your head, and unpleasant
feelings in your chest and throat, tummy—and
around that anxiety there’s a body, which you can
move…and see if you can notice that body…and
gently move it, have a stretch (therapist moves,
stretches, and client copies)… That’s it, take
control of your arms and legs.
And also notice the room around you (therapist
looks around the room, client copies)… So see if
you can get a sense of it all—the feelings inside
you, and your body around the feelings, and the
room around your body… And also notice you and
me here, working together as a team… (playfully)
doing this weird exercise. (long pause) Okay, so
those are the basic steps. Can we run through that
again, and this time I’ll talk less?
Client: Okay.
 But I Want to Get Rid of the Storm!
Suppose the exchange above had gone a bit differently:
Therapist: And just to be clear, this isn’t a way to control
your feelings. It’s a way to hold yourself steady—
even as the storm rages inside you.
Client: But I don’t want the storm to rage inside me.
Therapist: Of course you don’t, it’s really unpleasant. And I
promise later we’ll have a look at what we can do
about that—but right now, what we’re doing is
dropping anchor, and that’s not a way to control
storms.
Client: So what’s the point of it then?
Therapist: Well, basically there are three main aims…
(Therapist runs through the aims.)
Such reactions are not uncommon, early in therapy: That’s not what
I want. I want to get rid of these feelings. I want to stop feeling this way.
We can normalize and validate these wishes, and reassure clients we will
soon address it: “Yes, absolutely. Naturally, you want to get rid of these
feelings. They’re very painful—and I promise you, we’ll look at that
shortly. I just want to be clear that, right now, with this particular skill,
that’s not the aim.”
When the time is right, we compassionately explore the client’s
perfectly natural agenda of experiential avoidance—and gently
undermine it through the oddly named process of “creative
hopelessness” (chapter twelve). And when is the right time to do that?
Well, as you know, there’s no “fixed” or “right” order for TFACT—
however, it’s often useful to loosely follow this sequence:

1. Behavioral goals (extracting values if possible)

2. Dropping anchor
3. Defusion
 4. Creative hopelessness
5. Acceptance

This sequence works well for two reasons: (1) to accept painful
emotions is the hardest part of TFACT for most people, and it’s usually
much easier when dropping anchor and defusion skills are in place; and
(2) when we establish goals first, they provide the motivation for
acceptance: we make room for difficult feelings so we can do what
matters.
Having said all that, we want to be flexible. So if a client remains
opposed to dropping anchor and insists, “I just want these feelings to go
away,” we’d usually move into creative hopelessness.

Do We Have to Follow the A-C-E

Sequence?
No, we don’t. Some clients find it easier to first connect with their
body before moving into the other stages. The ACE formula helps clients
and practitioners learn and remember the three core components of
dropping anchor; however, as therapy progresses, we want to encourage
flexibility by playing around with the order. For example, we may go
from E to C to A; or from C to A to E; or from A to C, then back to A,
back to C, then to E, and so on. (You’ll see an example of this in the next
chapter.)

How Long Does Dropping Anchor Go

For?
Exercises continue until the client has good control over their
physical actions and is psychologically present: engaging in the session,
attentive and responsive to the therapist. Presence might be indicated by
nonverbal responses (e.g., facial expressions, body posture) or verbal
responses (e.g., speaking readily, asking or answering questions,
verbalizing thoughts and feelings).
Usually two to four minutes is enough—but in cases of intense
fusion, overwhelming emotions, or dissociation, this may go for much
longer; on rare occasions, even ten to fifteen minutes. At the other
extreme, when clients only “drift off” slightly or “zone out” a little, a
ten-second version might be enough.
Occasionally in supervision, a practitioner complains, “We dropped
anchor, but the client was still really fused at the end.” This represents a
misunderstanding. Dropping anchor is not a script we follow for a set
amount of time or a fixed number of repetitions; it’s an interactive
process that continues for as long as necessary. If the client is “still really
fused,” then we are not “at the end”; we keep going and work with that
fusion:
Therapist: (Acknowledging) So notice, your mind is still beating
you up here, still telling you all the things that are
wrong with you. And we’re not trying to stop your mind
from doing that; the aim is simply to acknowledge it. So
say to yourself, “I’m having thoughts that XYZ (XYZ =
thoughts the client is fusing with).” And at the same
time, notice there’s a body here you can control, even
with all these thoughts present…
Similarly, sometimes a supervisee complains that the client was
“triggered” by dropping anchor; they were feeling relatively calm and at
ease before the exercise, but when they started it, difficult thoughts and
feelings (usually anxiety) showed up. This doesn’t happen often, but
when it does, it’s a good opportunity to practice flexible responding. We
might say:

So notice what’s happening now. Your mind is fueling the

emotional storm, making it bigger and stronger. Is it okay to keep
working with this?
Remember, we’re not trying to make the storm go away; anchors
don’t control storms…
 So now, say aloud, “I’m noticing my mind worrying”…and “I’m
noticing feelings of anxiety”…and “I’m noticing the storm getting
stronger”…
So noticing those thoughts and feelings are here right now, also
stand up, just like I’m doing, and ever so slowly, let’s stretch…and
notice that even though the anxiety storm is raging, you have
control over your arms and legs…

In this manner, we continue working with the anxiety until the

client is anchored. (In chapter twenty we’ll explore how this plays a
central role in working with panic attacks.)

Scaling Client Responses

There are two useful scales for tracking client responses when
dropping anchor—one for contact with the present moment, and the
other for control over physical action.
For contact with the present moment, we say, “On a scale of zero to
ten, where ten means you’re fully present here with me, you know,
you’re engaged and focused and really tuned in to what we’re doing, and
zero means you’ve completely drifted off, you’ve sort of checked out of
the room, gone off somewhere else in your head, lost track of what we’re
doing or what I’m saying—the very opposite of focused and engaged…
then zero to ten, how present are you right now?”
For control over physical action: “On a scale of zero to ten, where
ten means you’ve got full control over your physical actions—what you
do with your arms and legs, hands and feet—and zero means you’re
completely frozen, locked up, can’t move at all…then zero to ten, how
much control do you have over your actions right now?”
Both of these are useful scales to establish early on in therapy. They
help us track a client’s responses and gauge the need to go for longer. If a
client answers seven or eight, that’s usually enough to end the exercise,
and if they reach nine or ten, that’s excellent. Below a seven, we
probably need to keep going, and ramp up the physicality of the exercise,
for example, stand up and stretch, walk around the room, or reach out
and drink a glass of water.
These scales are particularly useful for telehealth, especially audio-
only. They enable us to do regular check-ins: “Zero to ten, how present
are you?” or “Zero to ten, how much control do you have over your
actions?”

When Do We Introduce Dropping

Anchor?
As mentioned earlier, if during intake a client is overwhelmed,
having flashbacks, or experiencing extremes of arousal, it’s wise to put
all other tasks on hold and teach them to drop anchor. Similarly, if a
client turns up (to any session) in a state of extreme hypo- or
hyperarousal, although we obviously want to know what has happened,
our first priority is to help them respond effectively to their physiological
state; later, once they are centered and engaged, we can find out what
triggered their reaction.
So basically, the sooner we introduce dropping anchor, the better. If
we introduce it in session two (i.e., the session after intake), we might
say, “There’s a lot more I’d like to ask you about, but as I said earlier, a
big part of our work here is learning new skills to handle all these
difficult thoughts and feelings more effectively—take the power and
impact out of them—and so if it’s okay with you, I’d like for us to make
a start on that. Would that be okay?”

Debriefing
In this section, we’ll look at how to debrief dropping anchor exercises.
After an exercise ends, useful questions to debrief it include:

What happened? What did you notice? What changed?

 Is it any easier for you to engage with me, to be more present?
Are you able to focus more on what I’m saying? Tune in to what
we’re doing?
Do you have more control over your physical actions now—over
what you can do with your arms and legs and mouth?
Are you less hooked by these difficult thoughts and feelings? Are
you less “swept away” or “jerked around” by them?
Are you able to be present with me, even with that difficult stuff
still here?

Note that we don’t ask if anxiety has reduced, the memory has
gone, or the client is “feeling better.” That would send the wrong
message. (Of course, emotional pain does usually reduce—but in ACT
that’s a bonus, not the main aim.) So if the client says something like
“Wow; I feel a lot better. My anxiety has really dropped,” we could
reply, “That’s not uncommon. So by all means, enjoy that when it
happens. But please don’t expect it; that’s not the aim.” If the client
seems confused, surprised, or disappointed, we then clarify what the aim
is. (We may also encounter the flipside: “It’s not working” or “It didn’t
help.” In other words, they expected to feel relaxed, calm, or happy.
Once again, this requires patient clarification.)
When a client can talk freely—as in the earlier transcript with Jeff
—we ask about their thoughts and feelings before launching into the
exercise. But if a client can’t or won’t speak—as in the transcript with
Lottie—we can “work blindly” to begin with. Then once the client is
centered, engaged, and ready and able to speak, we can find out what
happened:

What was going on for you?

What sort of difficult stuff showed up for you? What sort of
thoughts, emotions, memories?

We also explore how this skill could be useful outside the therapy
room:
 So what just happened there—do you ever have reactions like that
outside this room? What do you usually do when that happens?
Suppose you were to run through this exercise next time that
happens—how do you think it might help?
How might this skill be useful: At home? At work? At play? In
your relationships? (When, where, with whom, doing what?)

Modifying
As with any intervention, first and foremost we need to take our clients’
individual needs and circumstances into account. Below we’ll go
through some ways to modify dropping anchor exercises for different
issues.

Modifications for Flashbacks and

Intrusive Thoughts
We can think of a flashback as a state of extreme fusion. The client
is so fused, they do not experience it as a “memory” (a “recording” or
“impression” of a past event). It’s as if this event is happening in reality
—right here and now. There is no sense of “I”—the observer—noticing
this experience; no sense of historical narrative attached.
Dropping anchor is a good first-line intervention for flashbacks.
However, in the Acknowledge phase, we name the private experience as
“a memory.” For example: “Here is a memory,” “I’m having a memory,”
or “My mind is replaying a memory.” So by the end of the first ACE
cycle, we may be saying: “Acknowledge, there’s a painful memory here
right now…and some painful feelings that go with it…and around all
that is your body…so again, just move and stretch a little…and notice
you can control your actions even with this memory present…and notice
there’s also a room around you…and see if you can get a sense of it all at
once…the memory, and the feelings, and your body, and the room
around you…and you and me working here together, as a team…”
 Our next step is to link this memory to a historical narrative. (To
understand the science behind this, and how you might explain it to
clients, see Extra Bits.) As soon as the client can speak freely, we ask
what the memory is, then add that information into the naming. For
example: “Here is a memory of the car crash,” “I’m having a memory of
family violence,” “My mind is replaying a memory of sexual assault.”

Practical Tip
It’s important to name memories nonjudgmentally. If a client
uses a phrase like “Here is a memory of that bastard ruining my
life,” it’s likely to increase fusion.

We use similar modifications for intrusive distressing thoughts,

acknowledging them with phrases like “Here is a thought” or “Here’s
that thought again,” or “I’m having a thought about XYZ.”

Modifications for Distractibility

Many types of mindfulness practice develop your ability to focus.
Initially, they have you focus your attention on some specific stimuli
(e.g., the flow of your breath). And of course, after a while your attention
wanders. The moment you realize this has happened, you acknowledge it
and note what distracted you (e.g., thoughts, feelings, sights, sounds).
And then, you refocus on the chosen stimuli. When we help clients
develop task-focused attention in this manner, it’s a useful antidote to
distractibility and disengagement, and a good practice for disrupting
worrying, rumination, or generally “getting lost in thought.”
We can easily adapt dropping anchor to serve such purposes. After
two or three rounds of ACE, as the client becomes more centered and
engaged, we ask them to focus their attention on something—their
breathing, or the sensations in their feet, or the sounds in the room—and
keep it there. And then, as with any attention-training practice, we
encourage them to notice when and by what they get distracted—and
then refocus. You can do this for several minutes (or much longer)
before ending the exercise. In Extra Bits you’ll find a script for
traditional attention training through mindfulness of the breath, and
another that incorporates this practice into dropping anchor.

Modifications to Disrupt Problematic

Behavior
We can use dropping anchor to disrupt almost any problematic
overt or covert behavior. We modify the Acknowledge component as
follows:

For covert behavior such as worrying, ruminating, and obsessing:

Here’s ruminating, I’m having obsessive thoughts, I’m noticing my
mind criticizing me, Worrying again.
For urges to do self-defeating behavior: I’m noticing the urge to cut
myself, Here’s an urge to drink, Wanting to scream.
When clients “catch themselves in the act” of doing something
problematic and they want to cease, they first acknowledge, Doing
it again; time to stop. They then go on to acknowledge their
thoughts and feelings.

Aside from these modifications, the rest of the process is the same.
Cycling through ACE will often help clients interrupt the problematic
behavior or help prevent them from acting on an urge.

Modifications to Develop Core

TFACT Skills
As therapy progresses, we may extend the Acknowledge component
to develop acceptance skills—encouraging clients to notice, name, allow,
and open up to their feelings. We may also do this for defusion—taking
more time to notice, name, and allow—then actively observing the flow
of cognitions. We may also extend the Connect component: spend much
longer on tuning into the body to develop somatic awareness or practice
interoceptive exposure (i.e., exposure to physical sensations). See Extra
Bits for tips on how to modify exercises not only for all of the above, but
also to develop values, committed action, and self-as-context.

Homework
After dropping anchor for the first time, it’s good to set it as homework
and encourage daily practice, clearly linking it to issues raised in session.

Assigning Homework
Depending upon the purpose of the homework, we may introduce it
by saying things like:

This is your “go to” whenever emotional storms blow up.

Do this whenever you get hooked by your thoughts and feelings.
You can use this with flashbacks, to help yourself unhook from the
memory and get back into the here and now.
When you’re all caught up in worrying, you can use this to pull
yourself out of it.
This is “first-aid for emergency shutdown.” If you’re starting to
zone out, or freeze up, or check out of the room—or if you sense
that you’re about to—this is what you need to do immediately.

We also clarify that after the exercise finishes, the idea is to focus
on and engage in the activity you are doing, unless of course that activity
is problematic—in which case, the aim is to stop it, and instead do
something more life enhancing.
And we always emphasize the need for regular practice:
 Therapist: The idea is to practice several times a day—
especially at times when you’re not too distressed.
You know, when you’re just a little bit anxious, or
angry or upset about something. Like when you’re
stuck in a line or traffic jam, or you’re running late
for an appointment, or someone does something
that irritates you. If you practice this a lot when
you’re just a little bit distressed, it builds up your
psychological muscles, so then you’ll be able to
handle it when the really difficult stuff shows up.
Would you be up for that?
Client: Yeah, I’ll try.
Therapist: And also, see if you can do a ten-second version
of this, any time you’re “drifting off”—you know,
when you’re a bit lost in your head, not really
focused on what you’re doing. And I do mean
literally ten seconds. You just acknowledge
whatever thoughts and feelings are present, and
come back into your body—straighten up or
stretch or push your feet down—and then notice
where you are, and refocus on what you’re doing.
In Extra Bits, you’ll find a client handout on dropping anchor, with
hyperlinks to audio recordings, varying in length from one to eleven
minutes. You can encourage clients to listen to one or two of them, daily.

Following Up on Homework
At the start of the next session, we aim to debrief the homework and
troubleshoot any problems.

DEBRIEFING
When following up on homework, we ask when and where the
client practiced it, what happened, and what difference it made. Did they
modify the practice? Were they able to notice and name their thoughts
and feelings? Allow themself to be present without a struggle? Did they
take control of their physical actions? Refocus and engage in activities?

TROUBLESHOOTING
Two common problems with any mindfulness homework are (a)
people misuse it to try to control their thoughts and feelings, or (b) they
don’t do it. We’ve already covered the first problem; we’ll address the
second in chapter eighteen.
Occasionally a client says, “It’s fine dropping anchor when I’m
alone, but I don’t want to do it around other people because they might
judge me.” Their assumption is that dropping anchor needs to involve
obvious physical movements, such as stretching. But this is erroneous.
You can easily drop anchor in ways that others can’t observe. For
example, if you’re socializing, you can take a moment to acknowledge
your inner world, gently push your feet into the floor or straighten your
spine, then refocus on the conversation—without anyone else knowing.
Ideally, we’d ask the client to practice this in session, to ensure they get
the hang of it.
Sometimes a client complains they were “too overwhelmed to drop
anchor,” or says, “By the time I realized what was happening, it was too
late.” There are three aspects to dealing with such issues: regular
“mindful check-ins,” planning ahead, and “building up.”

Mindful check-ins. We can encourage clients to do “mindful check-ins”

throughout the day: to pause for a few moments and notice their thoughts
and feelings, and gauge how tense, stressed, or upset they are. This way,
they learn to recognize when they are getting “wound up” or “things are
building up”— and drop anchor “before it’s too late.”

Planning ahead. We can encourage clients to anticipate and prepare for

high-stress situations. When and where are emotional storms or
dissociative states most likely? Doing what and with whom? Ideally, as
therapy progresses, clients will use more and more TFACT strategies to
prepare in advance for such challenges. Even briefly dropping anchor
before entering a high-stress situation can make a significant difference.

Building up. A useful metaphor is the idea of joining a gym to get fit. If
you go straight for the heaviest weights on your first visit, you’ll injure
yourself. So you start lifting light weights, and over time, you build up
your strength until you can safely lift the heavy ones. But even then, you
still first do warm-ups with the light ones.
The same principle applies to dropping anchor (or any other new
skill): clients first practice in less challenging situations; and they do so
repeatedly, progressively building up their skills. Eventually they can
apply these skills, even under high-stress conditions. Together, therapist
and client brainstorm situations and events that are useful for “building
psychological muscles”; anything that triggers mild-to-moderate levels
of stress, tension, or difficult emotions provides a good opportunity for
practice.

Where to Next?
The more distressed, shut down, or emotionally dysregulated the client,
the more important it is to continue doing this “bottom-up” work in
session. So we want to keep these exercises going in subsequent
sessions, further developing the client’s ability to drop anchor. But where
to, after that? Do we continue the bottom-up emphasis, primarily
working with emotions, sensations, and the body (as in chapters twelve,
thirteen, fourteen, twenty-two, and twenty-three) or introduce some “top-
down” work with cognitive defusion (as in chapters ten and eleven)? If
emotions, sensations, and physiological reactions are the predominant
issues, then the first option is probably better. Alternatively, if fusion
predominates (e.g., hopelessness, reason-giving, rumination, worrying,
self-judgment), then defusion is probably the best option. However,
either option is fine; we tailor what we do to suit the needs and
capabilities of each unique client. And at any point, if we get stuck
working on one core process, we can freely shift to working on an
another.
 EXTRA BIT In Trauma-Focused ACT: The Extra Bits, chapter
eight, you’ll find (a) a client handout on dropping anchor, with
hyperlinks to free audio recordings; (b) a generic script for
dropping anchor; (c) a script for training attention through
mindfulness of the breath; (d) a script incorporating mindful
breathing into dropping anchor; and (e) notes on incorporating
memories into historical narratives.

Takeaway
“Dropping anchor” is a term for hundreds of different exercises based on
the ACE formula: Acknowledging your inner world, Connecting with
your body, and Engaging in what you are doing. We can introduce it at
any point in any session, and it’s especially useful as a first-line response
to extremes of arousal, dissociation, flashbacks, extreme fusion, or
emotion dysregulation. It’s also a good foundation for defusion and
acceptance. Simple to teach, easy to learn, nonmeditative, trauma
sensitive, accepted across many different cultures, and useful with a
huge range of problems: the sooner we introduce it, the better.
 CHAPTER NINE.

Flexible Sessions

Congratulations. You’ve just made it through the longest chapter in the

book! In this much shorter one (breathe a sigh of relief), we’ll explore
how to structure our sessions. And like anything in TFACT, we want to
be flexible. If you’re going around in circles, sessions full of
compassionate listening but no active practice of TFACT skills, then
clearly you need more structure—but don’t cling rigidly to the sequence
I’m suggesting, which is:

1. Do a brief mindfulness practice.

2. Review homework.
3. Set an agenda.
4. Work through the agenda, item by item.
5. Assign homework.

Let’s take a closer look at each of these items.

A Brief Mindfulness Practice

It’s useful to start each session with a brief mindfulness exercise, lasting
three to five minutes. This helps the client and therapist center
themselves and primes both for an experiential session. (And it’s
especially useful with clients who don’t practice between sessions.)
 Practical Tip
After debriefing a client’s first formal mindfulness exercise, we
can ask, “Would it be okay to start each session doing
something like this?” Most clients agree, making it easy to
kickstart later sessions with some mindfulness.

Early on in therapy, we may use dropping anchor to start a session,

but later, as the client’s repertoire of TFACT skills grows, we may
choose exercises that focus more on defusion, acceptance, self-
compassion, or self-as-context. Ideally, we also include values in these
exercises:
Therapist: Is it okay to kick off with a short centering
exercise to help us both get into the space for a
productive session?
Client: Sure.
Therapist: Okay, so building on what we did last session…
(Connecting with the body)…taking a moment to
adjust your position in the chair…straightening
your spine, and letting your shoulders drop…and
gently pushing your feet into the floor…getting a
sense of the ground beneath you…
(Engaging with the outside world)…and fixing
your eyes on a spot, or closing them if you
prefer…and tapping into a sense of curiosity…as if
you are a curious scientist, exploring the world
around you…and noticing what sounds you can
hear…coming from you…and from me…and from
the room around you…and from outside the
room…
And noticing how you can shift your focus
between these different sounds…like you can
focus in on my voice…or you can focus on the
 traffic noise outside…or you can focus on the
sound of the air conditioner…
(Acknowledging thoughts)… And see if you can
notice the difference between the sounds you hear
and the thoughts that go with them…notice how as
soon as you hear a new sound, your mind locates
where it is and labels it with words or pictures…
I’m going to make a sound now, and notice what
your mind does… (therapist taps fingers on a hard
surface for several seconds, then stops)…and now
I’ll make another sound, and again, notice how
your mind locates it and labels it… (therapist taps
foot up and down on the floor for several seconds,
then stops)…
(Connecting with the body)… And now noticing
your body in the chair…and straightening up…and
having a stretch…and holding that stretch…and
really noticing the sensations of the muscles
stretching…and doing that again, but this time,
doing it in slow motion, and really noticing all the
tiny subtle sounds you make as you do so…
(Acknowledging thoughts and feelings) And
noticing what thoughts and feelings are showing up
for you right now…noticing whether they are
pleasant or unpleasant or neutral…and using that
phrase “I’m noticing” to silently acknowledge
whatever is showing up…and taking a moment to
tune into your values…to connect with why you
came here today…to remind yourself what’s
important to you, deep in your heart…what and who
you care about enough that you came here today…
and take a moment to acknowledge that even though
difficult thoughts and feelings showed up for you, you
didn’t let them prevent you from being here…

We typically finish this exercise by connecting with the body and

engaging with the outside world through the five senses. We then debrief
it, teasing out relevant points and tuning in to values and values-based
goals. (And if you prefer a shorter exercise, you can do the mindfulness
of sounds component as a standalone.)

Review of Homework
The next step is to follow up on the homework: What did the client do?
What happened, and how was it helpful? And if the homework involved
practicing a mindfulness skill, how often and for how long did they do
it? We also inquire about difficulties or adverse outcomes, and we
troubleshoot any problems the client encountered. And if clients haven’t
done their homework (yes, hard to believe, I know, but amazingly
enough, on rare occasions this happens!), we address this as in chapter
eighteen.

Setting an Agenda
It’s a good idea to set an agenda for sessions. Some therapists initially
resist this, complaining it’s “too directive.” However, once they accept
their discomfort and try it out, they find sessions become far more
productive. Furthermore, most clients respond very well; the agenda
helps them collect their thoughts and prioritize what’s important. Indeed,
for clients prone to “problem hopping” (jumping from one problem to
another, without creating an effective plan or strategy), learning to
prioritize problems is an essential skill.
The choice point offers a simple way to do this: “What would you
like to focus on today: working on unhooking skills or getting busy with
towards moves?” Another simple tool is the “bull’s eye,” illustrated
below.
The bull’s eye is widely used for exploring values and setting goals,
but it’s also a good visual aid for setting an agenda:
Therapist: So you can see this little tool divides life up into
four main areas—work, relationships, health, and
leisure. If we could pick just one of those areas to
focus on—to start making some positive changes
there—which would you prefer?
Client: Um, I think, relationships.
Therapist: Okay. Is there one relationship we could focus on
today?
 The Bull’s Eye

So how do you prioritize? There is no “official” TFACT way to

prioritize items on an agenda, but the following sequence works well:

1. Risk of self-harm. If there’s significant risk that clients may harm

themselves, this obviously takes priority over anything else. (See
chapter twenty-six.)
2. Teamwork troubles. Many things can cause tension or discord in
the therapeutic relationship: the client missing sessions, not
paying bills, or being aggressive or dismissive; the therapist being
coercive, invalidating, or lacking in empathy. We want to identify
the problem and address it as soon as possible. (See chapter
nineteen.)
3. Session stoppers. Next on the agenda are client behaviors that stall
or disrupt the session: repeatedly coming up with reasons why
therapy can’t work or why they can’t change, refusing to do
exercises, problem hopping, continually changing topics, and so
on. (See chapter nineteen.)
4. Homework horrors. If clients aren’t doing their homework, we
want to find out what the barriers are and help the client overcome
them. (See chapter eighteen.)
5. Other issues. For the remaining problems, there are several ways
to prioritize:
a. Encourage the client to choose: “Out of all the issues
you’re dealing with currently, which one would you like
to tackle first?”
b. Use the bull’s eye; ask the client to pick just one
quadrant, and the most pressing problem within it.
c. Focus on whichever seems to be the least difficult
issue—the one most likely amenable to quick but
significant change.
Working Through the Agenda
Once the agenda is agreed upon, we work through it, item by item.
Occasionally an entire session may focus on just the first item, but often
we can cover several.
No matter what issues the client chooses to focus on, in each
session, we “dance around the triflex.” We begin each session with
“being present,” which gives us a secure foundation for “opening up”
(defusing from, accepting, and responding with self-compassion to
difficult cognitions and emotions). And if clients become overwhelmed
at any point, we drop anchor and bring them back to the present; then,
when they’re centered and willing, we venture forth once more into
“opening up.”
The same holds true for “doing what matters.” Clarifying values,
setting goals, and creating action plans can sometimes trigger
overwhelming emotions or extreme fusion. If so—yes, you guessed it—
we help clients drop anchor. Then, once they are present and centered,
we gently return to values and committed action. Naturally, some
sessions focus far more on one aspect of the triflex than the others, but
usually all three are involved to some extent.
When clients are in challenging situations, with little hope of short-
term resolution, a useful tool to cope is “the challenge formula” (Harris,
2015). This tool helps us to see that no matter how great the challenge
we are facing, we are not powerless. We have choices, as summarized
below.

The Challenge Formula

In any challenging situation, no matter what it may be, we always
have two or three of the following options:

1. Leave.
2. Stay and live by your values: do whatever you can to improve the
situation, make room for the inevitable pain, and treat yourself
 kindly.
3. Stay and do things that either make no difference or make it
worse.

Of course, option one—leave—isn’t always available. For example,

if you’re in prison, you can’t just leave. If you’ve got a serious illness, or
lost a loved one, you can’t simply leave that situation; wherever you go,
the problem goes with you. But, at times, leaving is an option—in which
case, seriously consider it. For example, if you’re in a toxic relationship,
an awful job, a violent neighborhood, or a profession that exposes you
repeatedly to traumatic events (e.g., emergency services or armed
forces), consider: is your life likely to be richer, fuller, more meaningful
if you leave than if you stay?
Now if you can’t leave or won’t leave, you only have options two
and three. Unfortunately, for most of us, option three comes quite
naturally: Stay and do things that either make no difference or make it
worse. In challenging situations, we easily get hooked by difficult
thoughts and feelings and pulled into self-defeating patterns of behavior
that either keep us stuck or exacerbate our problems. For example, we
may turn to excessively using drugs and alcohol, fighting with or
withdrawing from loved ones, dropping out of important parts of life, or
zillions of other self-defeating behaviors.
So the path to a better life lies in option two: Stay and live by your
values, and do whatever you can to improve the situation. And of course,
you can’t expect to feel happy when you’re in a really difficult situation;
it’s a given there will be painful thoughts and feelings. So the second
part of option two—make room for the inevitable pain, and treat yourself
kindly—is very relevant.
In the WHO’s ACT protocol for refugee camps, the challenge
formula comes early in session one. Obviously, option one is impossible
if you’re in a refugee camp—you can’t just up and leave—but options
two and three are both available. For example, there are people who
share the tent with you, and you can treat them with kindness, warmth,
and openness—or you can treat them with aggression, coldness, or
hostility. And the choices you make each day will alter your experience
within that tent. Likewise, when you step outside the tent, you can be
kind and friendly to your neighbors, or distant and hostile. And you can
join in with community activities, such as singing or prayer, or you can
isolate yourself. So all day long, you have choices that will affect your
quality of life within the camp.
It goes without saying that we need to be incredibly compassionate
and validating of the client’s difficulties when we present the challenge
formula. Provided we do so, it’s usually very empowering. It helps
people realize they have choices, even in awful situations. And it’s
especially important for clients where those challenging situations are
likely to persist, such as clients working in the armed forces and
emergency services, those living in prisons and other hostile
environments, and those continually exposed to racism, sexism, or other
forms of prejudice and discrimination. As part of option two, we always
emphasize the importance of reaching out to supportive others: friends,
family, community, and so on. This may take many forms; for example,
in the case of systemic prejudice and discrimination, this could involve
forming or joining groups that are politically active and campaigning for
change.

Practical Tip
We want to end each session safely, the client within their
window of flexibility. So we need to keep an eye on the clock
and make sure we allow enough time to help clients drop anchor
(or use other methods to center themselves) before the session
ends.

Homework
Ideally every session ends with a homework task. In early sessions, the
therapist typically suggests these, but as therapy progresses, it becomes
increasingly collaborative. (And if the homework task is a mindfulness
practice, have the client practice it in session first so you can
troubleshoot any problems.)
Before finalizing homework, we should assess: “On a scale of zero
to ten, where ten means ‘This is totally realistic, I’m definitely going to
do this, no matter what,’ and zero means ‘This is completely unrealistic,
there’s no way I’m ever going to do this!’—how realistic is it that you
will do this?”
If clients rate themselves lower than a seven, that bodes poorly for
success, so we should change the task: make it smaller, simpler, and
easier until the score reaches at least a seven.

EXTRA BIT In Trauma-Focused ACT: The Extra Bits, chapter

nine, you’ll find a printable version of the bull’s eye and a client
handout on the challenge formula.

Takeaway
There’s no official way to structure sessions in TFACT, but the principles
in this chapter are often helpful. In every session, we dance around the
triflex: being present, opening up, and doing what matters; and the
challenge formula helps apply these processes to ongoing difficult
situations.
In part two, we covered the important considerations for beginning
therapy. Now let’s delve into the first of the three interweaving strands of
TFACT—living in the present.
 PART THREE:

Living in the Present

 CHAPTER TEN.

Slipping the Shackles of Fusion

I’m a lousy therapist. I don’t know what I’m doing. I’m going to screw
this up. Does your mind ever tell you things like this? Yeah, mine too.
We have a lot in common with our clients! Most people think there is
something wrong with them for “thinking negatively,” so clients are
greatly relieved when their therapist, in classic ACT style, discloses,
“You know, your mind is a lot like mine. The things your mind says to
you are so similar to the things my mind says to me.”
Although we’ll cover many different defusion methods over the
next two chapters, I want to emphasize the importance of normalization.
Many clients with trauma consider their minds to be “damaged” or
“broken.” So over and over again, in a myriad of different ways, we
convey the message: your mind is not defective; there is nothing wrong
with you for thinking this way; the thoughts you are having are normal,
natural, and valid; we all have minds that think like this.

What Is Fusion?
Fusion means that cognitions dominate our awareness or our actions (or
both). This can cause problems in the following ways:
 A. Cognitions dominate our awareness. Examples include
worrying, ruminating, obsessing, dwelling on the past, fantasizing,
catastrophizing, “analysis paralysis,” blaming, judging, and so on.
This makes it hard to focus on the task at hand, engage in the
activity we’re doing, or be fully present with others. As a result, we
do things poorly, miss out on important aspects of our experience,
or cut ourselves off from others.
B. Cognitions dominate our actions. When we fuse with our
thoughts, beliefs, attitudes, assumptions, schemas, judgments,
rules, and reasons, they “dictate” our choices; we behave rigidly, in
ways that are usually problematic; we do things that take us away
from our values.
Technically, fusion means responding to cognitions with narrow,
inflexible repertoires of behavior, and defusion means responding with
broad, flexible repertoires. And these are not all-or-nothing states; we
might be “very fused” or “a little fused,” “completely defused” or
“slightly defused.” (With clients, we talk about “getting hooked” and
“unhooking yourself,” rather than fusion and defusion.)
In a state of fusion, cognitions seem like:

commands, rules, or laws we have to obey

important things that require our undivided attention
good advice to follow
threats we need to fight with or avoid
statements of absolute truth

In a state of defusion, we see our cognitions for what they are:

strings of words or pictures, changing from moment to moment,
continually coming and going. They may or may not be true. And
regardless of whether they are true or not, we don’t have to obey them,
follow their advice, treat them as threats, fight with them, avoid them, or
give them our undivided attention.
 The aim of defusion is not to reduce believability in thoughts, or
make them go away, or reduce emotional pain—although all these
outcomes are very common. The aim is to enable flexible responding to
cognitions—so they don’t dominate us, so we can act effectively and
utilize them if helpful. (If that surprises or confuses you, please repeat
the Hands as Thoughts exercise in chapter two, to clarify the costs of
fusion and the aims of defusion.)

Form Versus Function

In TFACT, instead of looking at thoughts in terms of their “form”
(i.e., whether their content is true/false, positive/negative,
optimistic/pessimistic, rational/irrational, and so on), we look at them in
terms of “function” (i.e., the effect they have on behavior).
A so-called “positive thought” (i.e., positive in terms of its content)
may have negative functions (i.e., problematic effects on behavior). For
example, a positive thought like I’m fantastic at my job, and I know
better than anyone else how to do it may foster narcissistic behaviors
that have a huge negative impact on workplace relationships.
Similarly, a so-called “negative thought” (i.e., negative content)
may have positive functions (helpful effects on behavior). For example,
the negative thought I might fail this exam may motivate a student to
study sufficiently. If our thoughts have helpful functions (i.e., they help
us to behave like the sort of person we want to be), then we let them
guide us. If not, we allow them to come, stay, and go in their own good
time—neither fighting nor avoiding them.

First Dance in the Dark, Then Lead to

the Light
I’ve previously used this poetic term in other textbooks to
emphasize the importance of a calm, patient, empathic approach to
defusion. When our clients are lost and stumbling in the thick darkness
of fusion, most of us have a strong urge to quickly flick on the bright
flashlight of defusion to illuminate the way out. But we need to be
cautious. If we rush into defusion too quickly, then despite our best
intentions, it’s likely to fail: to invalidate the client, trigger resistance, or
backfire and create even more fusion. So we first empathize with the
client, listening with openness and curiosity, looking at things from their
point of view, understanding how they feel, acknowledging their
difficulties, and validating their emotions.
“Dancing in the dark” means responding authentically and
compassionately to the client while they are fused—helping them to feel
heard, seen, understood, and validated. Typically, this doesn’t take long.
Sometimes therapists spend most or all of the session doing this work,
and that can be counterproductive. For example, suppose the client is a
“therapy veteran”; they’ve been in therapy for years, have told their
narrative many times before, and yet they remain firmly stuck. They like
attending therapy because of the empathy, understanding, and kindness
they receive, but their self-defeating behavior does not change. In this
case, doing yet another session comprised mostly of reflective listening,
validating, and empathizing will not help the client to make meaningful
life changes. If anything, it’s likely to reinforce their fusion and sense of
stuckness.
On the other hand, if the client has never been to therapy before and
is disclosing sexual abuse for the first time, that’s a very different
scenario. We may spend much longer dancing in the dark with this
client, to good therapeutic effect. However, if they should start
dissociating or becoming overwhelmed while they are trying to talk
about their trauma, we need to introduce practical skills straight away to
help them handle that reaction. If we just sit and listen and ask questions
and empathize while the client is dissociating or becoming
overwhelmed, that’s obviously harmful.
In other words, as with everything in TFACT, we need to tailor
what we do to suit each unique client; what’s useful or appropriate for
one person may not be for another. Once we’ve danced in the dark long
enough for the client to trust us as a dance partner, we can then start
gently “leading them to the light.” In other words, we introduce a core
ACT process—not necessarily defusion; whichever process seems most
likely to be helpful—and use it to compassionately guide them to a place
of greater psychological flexibility.

Flexible Terminology
In TFACT, we often use the term “story” to encapsulate any type of
cognitive content. However, occasionally a client finds this term
invalidating. If so, we would immediately reply, “I’m so sorry. I wasn’t
trying to trivialize or discount what you’re saying. All I mean by ‘story’
is a collection of words or pictures that convey information. I won’t use
that term again, if you prefer.” This will usually salvage the situation, but
to minimize the risk of invalidation, we may prefer not to use the term
“story.” Good alternatives include cognitions, beliefs, narratives,
schemas, themes, statements, assumptions, ideas, accounts, histories, and
judgments.
Even the term “thoughts” can sometimes elicit a negative reaction:
Therapist: Do you notice how these thoughts about being
worthless keep popping up?
Client: They’re not thoughts, they’re facts!
Therapist: (pauses for a few seconds) Okay, how about we
call them something else—like cognitions or self-
judgments?
Client: But they are true!
Therapist: You sound as if you’re expecting me to challenge
you?
Client: Well—yes. That’s what the other therapist did.
Therapist: In some models of therapy there’s a big focus on
whether your thoughts are true or false—but not in
this one. In ACT, we don’t get into that.
Client: Oh. (looks surprised) Okay.
 Therapist: What we’re interested in is what you do when
these cognitions show up. If you give them all your
attention, or do what they tell you to do, does that
help you to build the sort of life you want? If it
does, there’s no problem. But if not, are you
interested in learning how to unhook from them?
Clients are most likely to insist their thoughts are true when
previous therapists have disputed them or made dismissive remarks like
“It’s just a thought.” Clients are often surprised to find that this isn’t
going to happen in TFACT. (Indeed, one of the most impressive things
about defusion is that it reduces the believability of false or inaccurate
cognitions without needing to dispute them.)
Some clients have heard that “Thoughts are not facts,” a phrase that
can easily be invalidating. If so, we can explain that “facts” are indeed a
type of thought:
Therapist: The brain generates thousands upon thousands
of thoughts all day long. Some of them are facts,
some are opinions, some are judgments, some are
lyrics from songs or lines from movies or popular
sayings or jokes—or a zillion and one other things.
Did you ever have some really weird thought pop
up and wonder, Where the hell did that come
from?
Client: Man, you have no idea—the shit that goes through
my head!
Therapist: Yeah, mine too. So when I use the word
“thought,” I mean it as a catch-all phrase, to
include all of these different things—from hard
facts everyone would agree with to crazy weird
shit that comes from who knows where. If you
prefer, I can use the term “cognition.”
 Exploring Thoughts
We can usually identify fusion without directly asking about it. As
the client tells us why they’ve come, what they’ve been through, and
what their problems are, we’re likely to observe plenty of fusion with all
the categories mentioned in chapter two: past, future, self-concept,
reasons, rules, and judgments. Sometimes, however, direct questions are
useful, such as the ones below:

To elicit self-concept:
If I could listen in to your mind when it’s beating you up, what
are the nastiest things I’d hear it saying about you? What kind of
things does it judge you for?

To elicit past and future:

Do you ever get caught up dwelling on the past? On what sort of
things?
Do you worry much? About what? What does the future look like to
you?

To elicit reasons and rules:

What stops you from doing X (desired behavior)?
What keeps you doing Y (problematic behavior)?

To elicit judgments:
What does your mind have to say about that?

To explore the origins of cognitions:

Does this remind you of anything from your past? What’s the
earliest you can remember having such thoughts? Did anything
happen back then that feeds into this?
 To explore what triggers these thoughts:
How often do these thoughts show up? When? Where? With
whom? Doing what?
Are these thoughts connected to something that really matters to
you? Someone or something you deeply care about?

Identifying Themes
We’re interested not only in thoughts, but also in the emotions,
urges, sensations, memories, and impulses that accompany them. We
may ask:

How do you feel when your mind says these things?

Do any emotions show up? Urges? Sensations? Impulses?
Memories?

A useful strategy for defusion or acceptance is to identify themes

that link all these private experiences. There are two ways to initiate this:
as a teacher and as a detective.

TEACHER MODE
In teacher mode, we give the client a list of common patterns of
fusion and ask which they relate to. In Extra Bits, you’ll find three such
worksheets: “Twelve Common Themes,” which lists core beliefs,
narratives, and schemas; “Big Six,” which lists the six main categories of
fusion; and “Relationship Roadblocks,” which lists common cognitive
patterns that fuel interpersonal problems. (You can also use lists from
other models—for example, the eighteen schemas of schema therapy, or
the twelve types of “dysfunctional” thinking in cognitive therapy—but
remember that in TFACT we don’t dispute cognitive content or evaluate
thoughts as “distorted” or “dysfunctional.”)
Teacher mode is most useful for groups, clients with limited self-
awareness, or settings with limited time. In this mode, we might say,
“Often our thoughts cluster around themes, and as a first step in
unhooking, it’s useful to identify what they are. This sheet lists some of
the most common ones. Does your mind tend to favor any of these?”

DETECTIVE MODE
In detective mode, much like Sherlock Holmes, we “put the pieces
together” and reach a conclusion that makes sense of it all. For example:

Many of these thoughts and feelings seem to revolve around a

common theme, and I’m not quite sure how to phrase it—I’m
tempted to call it “unmet needs” because it seems to be about how
your needs aren’t getting met by other people; like they aren’t
taking into account what you really want. Does that seem about
right?
A lot of these thoughts and feelings seem to be about doing things
“right” and “properly” and to a really high standard—and beating
yourself up if you don’t manage. I usually call this “perfectionism”;
are you okay with that term?
There are so many painful thoughts and feelings and memories
here, going all the way back to your childhood, and they all seem
linked to the same theme: “I’m a failure.”

After suggesting a term, we check: “Is that a fair way to summarize

it?” (and of course, we change it if the client doesn’t approve). Better
still, the client names the theme:
Therapist: So there’s a whole stack of pain linked to this
issue—thoughts and feelings and memories, going
all the way back to age four, when your mom’s
boyfriend first started beating you. Now suppose
we could somehow magically put all those
thoughts and feelings and memories into a
documentary that contains them all. And you might
never show this documentary to anyone—or you
might choose to share it with someone you really
trust. But the idea is to come up with a short title
 that encapsulates the main theme. I know there
are a few different ones, but we just want the main
one, and a few words that sum it up. For example,
the catch-all theme that fits everyone’s
documentary is “not good enough.” So, you can
use that if you like—the “not good enough” theme
—but maybe you can come up with your own, like
the “rejection” theme or the “useless” theme. Any
ideas?
Client: Um, I think maybe, worthless, or um, unlovable?
Therapist: Okay. We can always change it later. For now,
can we call this the “worthless, unlovable” theme?
Client: Sure.
Identifying themes helps clients to notice and name their cognitions
—the first two steps in almost all defusion techniques—and it’s good to
make this explicit:
Therapist: One of our aims here is to spot that theme as it
shows up in our sessions; we want to call it out, catch it
in the act. Because as you get better at actively
noticing this theme—and all those feelings and
memories that go with it—you start to take some of its
power away. It’s the first step in learning to unhook.
We then ask for permission: “So is it okay to talk about it this
way?” Once the client consents, we can use this as a term of reference
throughout our sessions:

Is this feeling linked to “I’m a failure”?

And that triggered the “abandonment” theme?
Do you notice what your mind just did there? Another version of
“Bad Mother”?
When you get hooked by “can’t trust them,” what do you do?
Strategies Galore
There are well over a hundred different strategies for defusion described
in various texts (for an overview, see ACT Made Simple, 2nd ed., pages
140 to 155 [Harris, 2019]). In this chapter, we’ll focus on just a few of
them, beginning with the five simple strategies of Notice, Name,
Normalize, Purpose, and Workability.

Notice
All defusion strategies begin with noticing the presence of
cognitions. To help clients get better at this, we might ask, “What are
you thinking right now?” or “If I could listen into your mind, what
would I hear?” In formal mindfulness exercises, we might say, “Notice
what your mind is doing right now; is it silent or active?” or “Notice
your thoughts; are they pictures or words, or more like a voice in your
head?”

Name
As we notice our cognitions, we usually also name, or “label,”
them. Initially we tend to use generic terms like “thoughts,” “thinking,”
and “mind.” Then we may get more specific or playful: “Here’s the
‘unlovable’ theme again,” “There goes ‘radio doom and gloom.’” Often
we help clients develop these skills through formal exercises such as
“I’m Having t he Thought That…,” which we’ll look at shortly.

Normalize
Most clients have the idea that there is something wrong with them
for having so many “negative” or “weird” thoughts (especially if they’ve
been told their thinking is “irrational,” “distorted,” or “dysfunctional”).
So normalizing not only helps facilitate defusion but also fosters self-
acceptance. We may say, “Thoughts like this are normal. Your mind
sounds a lot like mine,” or “These thoughts make perfect sense given
what you’ve gone through; they’re a completely normal reaction.”

Purpose
We can reframe even the most “negative,” “problematic,” or
“unhelpful” thoughts by considering them in terms of the mind’s
purpose. We convey, in many different ways, that these cognitions are
the mind’s attempts to protect us and meet our needs: to help us avoid
what we don’t want or get what we do want. Below are a few examples
of how we might explain this—first in teacher mode, then in detective
mode.

TEACHER MODE
Worrying, catastrophizing, predicting the worst. This is your
mind trying to prepare you, to get you ready for action. It’s saying,
Look out. Bad things are likely to happen. You might get hurt. You
might suffer. Get ready. Prepare yourself. Protect yourself.
Ruminating, dwelling on the past, self-blaming. This is your
mind trying to help you learn from past events. It’s saying, Bad
stuff happened. And if you don’t learn from this, it might happen
again. So you need to figure out: Why did it happen? What could
you have done differently? You need to learn from this so you’re
ready and prepared and know what to do if something similar
should ever happen again.
Self-criticism for recurrent problematic behavior. This is your
mind trying to help you change. It figures if it beats you up
enough, you’ll stop doing these things.

DETECTIVE MODE
In detective mode, rather than explaining, we invite the client to
figure out the mind’s purpose. We may say , “Usually when our minds
are saying these things, there’s an underlying purpose; they’re trying to
protect us or help us to get something. Any idea about what your mind
might be trying to do?”
Useful questions include:

What might it be trying to protect you from?

What might it be trying to help you get? Or avoid?
Is it pointing to something that really matters to you?
Could it be trying to help you change your behavior?

We can usually quickly identify that pretty much any unhelpful

thought or thinking process serves the purpose of protection, self-care,
changing behavior, or getting our needs met. (Below you’ll see examples
for hopelessness and reason-giving, and in later chapters you’ll see how
to do this with suicidality, fear of trusting, and harsh self-judgment.) Not
only does this facilitate defusion, but it enables us to readily segue into
other processes, such as self-compassion and values, as we explore
alternative, healthier methods of self-care, self-protection, changing
behavior, or meeting needs.
After highlighting the purpose, we can introduce the Overly Helpful
Friend metaphor (Harris, 2015).

The Overly Helpful Friend

So basically, your mind is like one of those overly helpful friends
—you know, one of those people who’s just constantly trying to
be soooo helpful that they end up getting in the way, making
things harder. Genuine intention to help—but actually doing the
complete opposite. Well, that’s what’s going on here. Your mind’s
intention is not to (therapist names the adverse effects of fusion,
specific to this client [e.g., “make you feel worthless”]). But
unfortunately, that’s the effect it’s having.
For clients who believe in evolution, we can add impact to these
explanations by talking about the evolutionary origins of such thinking
processes (see “Caveman Mind Metaphors” in Extra Bits).
 Workability
The principle of workability offers a simple way to defuse. Instead
of examining thoughts in terms of their content, we look at how we
respond to our thoughts, and how those responses affect us. Basically,
we ask: When you let these thoughts guide you, where does that take
you? Towards the life you want, or away from it?
A good first step is to identify the problematic behavior that results
from fusion. This may be covert (e.g., worrying) or overt (e.g., social
withdrawal). In detective mode, we ask questions like:

When these thoughts show up, what do you usually do?

What happens if you do what they tell you to do?
If I were watching you on a video, how would I know that you had
been hooked by these thoughts? What would I see you doing or
hear you saying?

In teacher mode, we can pull out an Away Moves Checklist (see

Extra Bits) that lists common patterns of fused behavior and ask which
are relevant. Once we know what the fused behavior is, we can then ask
a workability question:

And in the long term, what direction does that take you?
And would you call that a towards move or an away move?
And is that more like the sort of person you want to be—or less?
And what (or who) does that take you away from?

Of course, we ask these questions with genuine curiosity and

compassion. (No point scoring, judging, or shaming the client.) Here’s
an example:
Therapist: So when your mind starts laying into you—
pulling out the “damaged goods” theme—what
usually happens?
Client: I get really down.
Therapist: So if I were watching a video of this, what would I
see or hear you doing on that video that would tell
me, “Wow! Siobhan has really gotten hooked by
this! She’s really down”?
Client: Different things. Like, if it was at home in the
evening, you’d probably see me going into my
bedroom and crying.
Therapist: And who does that take you away from?
Client: Mike. He hates it when I leave him.
Therapist: So, it takes you away from the sort of
relationship you’d like to have with Mike?
Client: (sighs, looks downcast) Yeah.
Therapist: That’s hard. Can I ask what you’re feeling right
now?
Client: I’m not sure. I’m just…really down.
Therapist: Where are you feeling this in your body?
Client: (tearing up) My eyes. (wipes tears away, apologizes)
Sorry.
Therapist: Please—tears are always welcome in this room.
They show you’re in touch with something very
important.
Client: (looking down) Thanks. I’d like to stop crying so
much. I can’t help it.
Therapist: What you’re going through is tough. Tears are
only natural. Unfortunately, society teaches us that
we need to hide them away—because, if I’m
crying, what does that mean?
 Client: You’re upset?
Therapist: Well, usually, yes. Although I have been known
to cry at weddings.
Client: Me too.
Therapist: But when I am upset, and I’m tearing up, society
says, “That’s not okay.” I’m supposed to hold back
my tears—because if someone sees me crying,
what might they think about me?
Client: You’re weak.
Therapist: Yup. I’m weak, I’m a softy. Need to toughen up a
bit. (playfully) Swallow a concrete pill.
Client: (faint smile) Tell me about it.
Therapist: So, in this room, we don’t play by those rules.
Tears are always welcome; let ’em flow freely.
Client: Thanks.
Therapist: And what about the rest of your body? Are you
feeling this anywhere else?
Client: (sighs heavily) Yeah. It’s like there’s a plank on my
chest.
Therapist: A heavy one? (client nods) You also look like
you’re kind of…sinking into the chair?
Client: Yeah, I am.
Therapist: So, I’m guessing here, tell me if I’m off track, that
what you’re feeling here, is…sadness?
Client: Yeah.
Note how the therapist normalizes and validates the client’s
reactions and helps develop her skills in noticing and naming emotions.
The therapist now returns to workability and asks about what happens
when the client gets hooked in other situations, such as work and social
events. The therapist then summarizes:
Therapist: So when you get hooked by the “damaged
goods” theme, it pulls you away from some really
important things: quality time with Mike, important
meetings at work, joining in and engaging when
you’re socializing…
Client: Yeah.
Therapist: So I’m wondering, would you like to learn a new
way of responding to these thoughts, that’s very
different from what you normally do?

Bringing It All Together

When clients can notice and name their thoughts, acknowledge
them as normal, recognize their purpose, and look at them in terms of
workability—that’s a whole lot of defusion! In the transcripts that
follow, notice how these strategies are combined.

THERAPY SESSION: DEFUSION FROM

DOUBT AND HOPELESSNESS
Therapist: You look doubtful. (noticing and naming) What’s
your mind saying to you?
Client: Honestly? It’s saying this is a crock of shit.
Therapist: (normalizing) Well, I have to tell you—those
kinds of thoughts are so common. Most of my
clients have them at the start. (self-disclosure) And
to be honest, I had the same ones myself, when I
first had therapy.
Client: Really?
Therapist: For sure.
Client: Look, I’ve tried therapy before. I just don’t think this
is going to work. I’m sorry—I’m too fucked up. I
don’t think you can help me.
Therapist: (normalizing, purpose) Well, there’s a reason
why those kinds of thoughts are so common. Do
you know why?
Client: (joking) Because therapy’s a crock of shit?
Therapist: (laughing) Well, there are plenty of folks who’d
agree with you about that, but the reason your
mind says this stuff is that it’s actually trying to
protect you.
Client: What do you mean?
Therapist: (purpose) Well, therapy is a risk. You’ve tried
before and it didn’t work, and so now your mind is
trying to save you from what might turn out to be
yet another painful, disappointing experience.
Client: (a bit surprised) Yeah, well, it’s got a point, hasn’t it?
Therapist: (purpose) It sure has! A very valid point. Your
mind is doing its single most important job here;
trying to protect you from getting hurt.
Client: (shrugs) It’s just stating the truth—I’m a hopeless
case.
Therapist: (self-disclosure—to model noticing and naming)
I’m noticing I have an urge to debate this with you,
try to convince you that’s not true. (workability) But
I don’t think that would work, do you?
Client: (chuckles) No. As I said, I’m a lost cause.
Therapist: (workability) Cool, so let’s not waste any time on
debating that. (naming) So here’s the situation:
your mind says, “This won’t work. I’m a hopeless
case.” (workability) So there’s a choice to make
right now about how you respond to these
thoughts.
Client: They’re not thoughts! They’re facts.
Therapist: (warmly) I honestly don’t mind what we call them
—facts, cognitions, words—the point is your mind
says, (naming) “This won’t work. I’m a hopeless
case.”
Client: Why do you keep saying “your mind”? It’s not my
mind.
Therapist: Oh. Err, maybe I should call it something else.
What do you call the part of you that generates
thoughts?
Client: It’s my brain.
Therapist: Okay. (noticing and naming) So right now, your
brain is stating, “This won’t work. I’m hopeless.”
And there are basically two options (workability)
about how you respond to that statement. One
option is, you end the session because your brain
says it won’t work. The other is, you let your brain
keep saying that, and we continue the session and
see what happens. So, there’s a choice point here:
what are you going to do?
Client: Well, I’m here, aren’t I?
Therapist: Yep, you are. And there’s a choice to make right
now; your brain says this won’t work, so do you
get up and leave, or do you carry on?
Client: Well, I guess… I’ll carry on.
 Therapist: (warm, genuine) Thank you so much. I can see
how hard this is for you. And I really appreciate
that you’re willing to stay here and give it a go,
even though (naming) your brain says it’s
pointless. I really appreciate it.
Client: (surprised) Okay.
Whatever reasons clients give as to why they can’t, won’t, or
shouldn’t change their behavior, we can use the same five steps to help
them defuse: notice, name, normalize, purpose, workability. For
example, suppose the client has a philosophy of nihilism:
Client: Look, the fact is, life has no meaning. Nothing has
any meaning. There’s no point in doing anything—
because it’s all fucking meaningless.
Therapist: (notice, name) Those are valid thoughts.
(normalize) Many great philosophers throughout
history have said similar things. And I’m wondering
—have other people tried debating those ideas
with you?
Client: Yes.
Therapist: And who won?
Client: Me. ’Cause I’m right.
Therapist: Well, I am never going to debate this with you.
(purpose) The fact is, these thoughts, this
philosophy—has a protective purpose. It keeps
you safe.
Client: What d’you mean?
Therapist: Well, see, that philosophy helps you avoid taking
risks, trying new things, leaving your comfort zone.
Because every time you even think of doing those
things, your mind says, “There’s no point” and
talks you out of it. So it saves you from all the
 anxiety that shows up when we do those things.
And it also saves you from the possibility of getting
hurt—because sometimes when you try new
things, they go badly. So in the short term, this
way of thinking keeps you safe and reduces your
anxiety. (workability) At the same time, life involves
choices. Meaningless or not, each day you choose
whether to eat or starve; have a shower or not. Be
polite to me or not. And while all those choices
may be equally meaningless, they do have
different consequences. (speaking slowly, with
great compassion) So there’s a choice for you to
make right now. One choice is to stop therapy
because your mind says it’s meaningless—and if
that’s the choice you make, nothing changes; life
goes on exactly as before. The other choice is, we
carry on working together and find out what’s
possible—even though your mind says it’s
pointless.
As long as we are kind, warm, and compassionate when we present
these options to a client, they are unlikely to say “Let’s stop.” After all,
they’ve come to us for help; and they’ve often pushed through a lot of
discomfort to reach us. However, if a client ever does say, “Let’s stop,” a
pragmatic response is, “Well, you’re already here—so how about we
give it another ten minutes?” If they choose to continue, we express our
genuine appreciation, while also acknowledging their commitment.
Having said all that, we don’t want to be coercive. So if the strategy
above doesn’t help, or the client now seems to be “going along with it”
grudgingly, or you get the sense they’re just trying to please you, you’ll
want to press pause and explore those possibilities with openness and
curiosity (as discussed in chapter nineteen).
Here’s a shorter example:
Therapist: (debriefing a dropping anchor exercise) So what
did you get out of that?
Client: Ah…I don’t think it’s for me.
Therapist: Oh. Why not?
Client: Err…it’s just not me. I don’t do this kind of stuff.
Therapist: Oh—well, that’s good.
Client: (surprised) What do you mean?
Therapist: Well, our aim here is to try new things; things you
haven’t done before—new approaches to dealing
with your emotions. So (noticing, naming,
normalizing) when you’re having thoughts like “It’s
just not me” and “I don’t do this,” that indicates
we’re on the right track. Like, if you were thinking,
“Oh yeah, this is me, I’m so comfortable doing
this”—well, that would not be good; because it’d
mean you’re staying in the comfort zone, doing the
same old thing—and we know that isn’t working for
you.
Client: Oh. (thinks) Well, what I meant is, you know—doing
this stuff—it feels weird.
Therapist: Yes, absolutely. (normalizing) That’s what it feels
like when you step out of your comfort zone and
try something new. (purpose) This is your mind
looking out for you: the message is, “Be careful,
you’re entering new territory; this is risky.” As we
do this work together, these kinds of feelings will
show up, and (normalizing) your mind will say
things like that over and over again. And
(workability) there’s a choice for you to make: do
we give up on this work because your mind says,
“That’s not me,” or do we let your mind say that
and carry on?
 THERAPY SESSION: DEFUSION FROM
SELF-JUDGMENT
Client: I should have sorted this out a long time ago. I’m so
pathetic.
Therapist: (noticing and naming) Do you notice how you
keep slapping these really harsh judgments on
yourself?
Client: And so I should! I’m fucking pathetic!
Therapist: (normalize) Well, we all judge ourselves, and
sometimes that helps (purpose)—sometimes it
keeps us in line, stops us from getting too big for
our boots—and other times it kicks our ass into
gear. (workability) But I’m wondering…most of the
time, when you use that tactic—beating yourself
up, judging and criticizing—does it actually help
you?
Client: (pauses, considers) No, but it’s true. I am pathetic.
Therapist: I can notice my own mind arguing against that
statement, but (workability) I don’t think it would be
helpful if I tried to debate about it. Do you?
Client: No. Because it’s true. There’s no debate about it. I
am pathetic.
Therapist: (compassionately) I feel a twinge of pain every
time I hear you talk about yourself that way. I’m
wondering…what’s it like for you to be on the
receiving end of all that self-judgment?
Client: (looks sad) Pretty shitty.
Therapist: I’ll bet. You look sad.
Client: I am.
 Therapist: I’d feel the same way if I was getting hammered
by all that criticism. Are you feeling that sadness in
any particular part of your body?
Client: Here (touches central chest).
Therapist: Like a “heaviness in the heart”?
Client: Yeah.
Therapist: Yeah. Constant self-criticism takes a toll.
Client: Yeah.
If something like this were to happen later in therapy, we would
probably move into acceptance of emotions and self-compassion;
however, at this point, such a move could easily fail or backfire.
Therefore, the therapist continues with defusion.
Therapist: So I’m wondering, (workability) when you get
hooked by all these self-judgments, what typically
happens?
Client: What do you mean?
Therapist: I mean, do you tend to do towards moves—
things that make your life better? Or do you tend to
do the opposite, away moves?
Client: The opposite, of course. Shows how pathetic I am,
doesn’t it?
Therapist: (noticing and naming) Do you notice how quick
your mind is to judge you? It doesn’t give you a
break, does it? (workability) And it seems like
when these judgments hook you, they pull you into
away moves.
Client: Yeah.
Therapist: Like some of the things you mentioned earlier—
drinking, staying in bed, isolating yourself?
 Client: Yeah, or just giving up on shit. Doing nothing.
Therapist: (workability) So if we could do some work on
learning how to unhook from all that self-judgment,
to help you cut back on the drinking, get out of
bed, socialize, and be more productive, would that
be useful for you?

Actively Teaching Defusion Skills

So far we’ve been talking about “informal” or “indirect” defusion: the
therapist’s repeated use of comments and questions involving the five
strategies: notice, name, normalize, purpose, workability. This helps
clients become more conscious of their cognitions and see them from a
new perspective. But this is only the start. The essential next step is to
explicitly teach defusion skills—as a formal in-session exercise—and
encourage the client to practice them for homework.

Defusion Metaphors
It’s often useful at this point to introduce the Hands as Thoughts
metaphor, as follows: “Before we start learning how to unhook, can I
take you through a quick exercise to help you understand what we’re
trying to achieve?” This metaphor quickly clarifies the costs of fusion
and the benefits of defusion, and it highlights two essential points: (a)
defusion is not a way to get rid of thoughts (the hands are still present at
the end), and (b) we don’t dismiss or ignore thoughts; if we can use them
constructively, let’s do so.
There are many other metaphors for defusion. For example, we can
talk about spam emails; pop-up advertisements on Instagram or
Facebook; or annoying commercials on TV. If we use these services, this
unwanted stuff will keep showing up. But when it does, we have a
choice: we don’t have to read a spam email from start to end; we don’t
have to click on a pop-up ad; and we don’t have to keep watching TV
during the commercials.
I’m sure you can think of many others; just be wary of what is
playfully called “metaphor abuse”: pumping out metaphor after
metaphor in the hope that a concept will “get through.” With metaphors,
“less is more”; so stick to a few and reuse them often. (And if clients
aren’t learning to defuse or accept, don’t introduce more metaphors;
move into active skills training.)

Learning How to Notice Cognitions

If cognitive fusion is not a significant issue for a client, then we
move on to other parts of the model: experiential avoidance, remoteness
from values, and so on. But when it is a major issue, the first step in
defusion is to consciously notice cognitions. Most people can easily do
this, but sometimes a client says things like “I’m not having thoughts” or
“I don’t know what I’m thinking.” If clients lack the ability to
consciously notice their cognitions, we can:

1. Explain that “Everything you say or write is a thought. When we

say thoughts aloud, we call that ‘speech’; and when we write them
down, we call that ‘text’; but when we keep them ‘inside our
head,’ we call them ‘thoughts.’” From here, we can teach clients
to notice the thoughts they are saying aloud. For example, if they
say things like “I’m stupid,” we might reply, “So the thought ‘I’m
stupid’ just popped up. How often do you have thoughts like
that?”
2. Invite clients to sit silently for one or two minutes and just “Notice
what you want to say.” Or alternatively, give them a piece of paper
and pen, and ask them to “Write down anything you want to say.”
This includes things like “I don’t want to say anything,” “I’ve got
nothing to write,” “This is weird,” and so on.
3. Take them through exercises designed to help them “hear” or
“observe” their thoughts, as discussed in the next chapter.
 4. Ask clients to silently sing a song, or silently repeat a well-known
saying—and notice how they can “hear it” inside their head.

Practical Tip
When clients have difficulty identifying cognitions or emotions,
focus on the ones that show up throughout the session. Don’t
get sidetracked into trying to get them to remember what they
were thinking and feeling at various times outside of the
session.

Defusion Exercises
We start by teaching relatively easy defusion skills and then
progressively build up to more challenging ones (which we’ll cover in
the next chapter). Two simple exercises to begin with are “I’m Having
the Thought That…” and Naming the Theme.

“I’m Having the Thought That…”

This is one of my favorite exercises (adapted from Hayes et al.,
1999). The instructions that follow are the same as we’d give to a
client. Please try it on yourself with a harsh self-judgment that tends
to hook you.
First, pick a thought.
Now put that thought into a short sentence—in the form “I am
X.” For example, I’m not smart enough or I’m too fat.
Now for ten seconds, let that thought hook you. Buy into it.
Believe it. Give it your full attention.
Now, silently replay that thought—but this time, insert a phrase
at the start: I’m having the thought that… (For example, I’m having
the thought that I’m unlovable.)
Now do that again, but this time insert another phrase: I notice
I’m having the thought that… (For example, I notice I’m having the
thought that I’m worthless.)

So did you get a sense of unhooking yourself; stepping back or

separating from the thought? (If you didn’t, please try again with another
one.) With a client, we debrief this as follows:
Therapist: So what happened to the thought?
Client: It didn’t bite as hard.
Therapist: Did you get a sense of stepping back from it?
Like there’s a bit of space between you and the
thought?
Client: Yeah. It kind of shifted a bit.
Therapist: (referring back to the Hands as Thoughts
exercise) So if this is totally hooked (puts hands
over face) and this is completely unhooked (lowers
hands to lap), can you show me with your hands
what happened?
Client: Err, it was like… (puts hands over face)…this…
(lowers hands to chest height)
Therapist: Cool. So you’ve just learned an unhooking skill.
We can then revisit this technique throughout our sessions. Here are
two examples:
Client: Let’s face it. I’m a lost cause.
Therapist: So you’re having the thought that you’re a lost
cause?
Client: I can’t believe how pathetic I am.
 Therapist: Could you say that again, but this time, put a
phrase in front of it: “I’m noticing the belief that…”?
Client: Say that aloud?
Therapist: Well, you don’t have to, but if you’re willing to, it’s
better if you say it aloud.
Client: Okay. “I’m noticing the belief that I’m pathetic.”
Therapist: Did that make any difference?
Client: Yeah, I unhooked a bit.
Alternative phrases to “I’m noticing” include “I’m having a…”
“Here is…” and “My mind’s telling me…” (These are terms we’ve
already been using when dropping anchor, and they apply equally to
emotions, urges, memories, sensations, and so on: I’m having a feeling
of anger or I’m noticing the urge to smash something.) Although we’ve
focused on fusion with self-judgment, we can apply this method to any
cognitive content: I’m having thoughts about getting hurt, My mind’s
telling me she’s going to leave me.

Naming the Theme

This defusion strategy works best with a small sheet of paper or
index card. On one side, the therapist writes down key thoughts
linked to a common theme. (In telehealth settings, both parties have
a piece of paper, and both write down the same thing.)
Therapist: (holding up a sheet of paper that lists ten of the
client’s recurrent difficult thoughts) So this stuff
(points to the writing) keeps showing up, and
hooking you, right?
Client: Yeah.
Therapist: And still okay to call it the “worthless, unlovable”
theme?
Client: Yeah.
Therapist: Okay. (flips the sheet over) So on the other side
here, I’m writing a phrase that I hope will help you
unhook. (Therapist writes in large block capital
letters and reads it aloud while doing so.) “Aha!
Here it is again! The worthless, unlovable theme. I
know this one.” (If it’s telehealth, the therapist asks
the client to do the same on the back of their own
paper; if “in person,” the therapist passes the
sheet to the client). So this is an experiment.
Obviously I hope it’ll be useful, or I wouldn’t ask
you to try it, but I never actually know for sure. So
part one is you read through all those thoughts—
silently, inside your head—and you really let them
hook you, reel you in. Then once you’re really
hooked, you flip it over and silently read to yourself
what I’ve written on the other side there. And as
soon as you’ve done that, you check in with me,
tell me what happened.
Client: Okay. (reads the first side, looks distressed)
Therapist: Looks like you’re hooked.
Client: I am.
Therapist: Okay, now flip it over, and read the other side.
Client: Okay. (reads the other side; face lifts a little; looks at
the therapist, slightly surprised)
Therapist: What happened?
Client: Yeah, it helped. It kind of contains it.
Therapist: Helps you step back a bit? Unhook?
Client: Yeah.
 Therapist: Okay, now just let that paper rest on your lap
(client does so) and acknowledge—those thoughts
are there, right now—and how many times has
your mind told you this stuff?
Client: Millions.
Therapist: Yeah, so you don’t really need to read that paper
—you know all those thoughts by heart—so
acknowledge they’re here right now…and also any
feelings that go with them…and at the same time,
have a stretch, notice your body moving…and
notice the room around you…so those thoughts
are here right now, they’re not going away…and
there’s your body around them, which you can
move and control…and there’s a room around
your body…and you and me here, working
together…and how are you doing there?
Client: (smiling) Good.
Therapist: Give me a number. This is zero (puts hands over
face)—zero means completely hooked—thoughts
are totally dominating you, controlling what you do.
And this is ten (lowers hands to lap)—completely
unhooked—thoughts are still there but they’re not
jerking you around, you don’t have to obey them or
give them all your attention, you can just let them
be there while you get on with your life. What
number are you?
Client: About an eight.
Therapist: Great.
The zero to ten fusion scale above helps to track the client’s
responses. Had the client given a low score at the end, the therapist
would probably have moved into dropping anchor.
 Thanking Your Mind
This popular defusion strategy (Hayes et al., 1999) involves not
only noticing and naming but also appreciating the purpose of the
thoughts in question.
Therapist: So basically, next time your mind starts saying that,
see if you can, with a sense of playfulness, say to
yourself something like “Ah, thanks mind. I know you’re
trying to look out for me. But it’s okay—I’ve got this.”
And if your mind replies, “Ah, you’re such a loser!” then
once again, you say, “Well, thanks for sharing.”
Basically, you don’t debate, you don’t defend, you don’t
let your mind pull you into an argument. With a sense
of humor, you thank your mind for its comments, and
carry on with what you’re doing. And each time it tries
to hook you, same thing: “Thanks, mind!”
Note: the “thanks, mind” part isn’t essential. If you prefer, you can
use a phrase like “Here’s my mind trying to keep me safe again.” You
can also go a step further with this strategy and write a compassionate
letter to your mind—see Extra Bits.

Clarification and Psychoeducation

The concept of defusion can be a tricky one, and we often need to
clarify what it is and isn’t.

ACKNOWLEDGING AND ALLOWING

VERSUS DISMISSING OR IGNORING
A common misconception among both clients and newbie ACT
therapists is that defusing from thoughts means dismissing or ignoring
them. We may explain:
Therapist: So I just want to be clear, we’re not dismissing these
thoughts. If they’re telling us about something
 important that we need to deal with or face up to,
reminding us about something that really matters, then
we make use of that. We get into action, we address
the issue, we do something constructive—we use that
information to launch us into towards moves. On the
other hand, if there’s nothing useful in them, we let
them sit there and do their thing, and we get on with
our life.
Similarly, to distinguish defusing from ignoring, we might say,
“This is not the same as ignoring. Have you ever been to a café or bar
and there was music playing in the background that you really didn’t
like, or someone behind you with a loud, annoying voice? And did you
ever try to ignore it? Yes? And what happened?”
Most clients will report that trying to ignore or “not hear” a loud
noise—a barking dog, a lawnmower, a car alarm—makes it bother them
more. We can then say, “Yeah, so the trick is to acknowledge the noise is
there. Don’t try to ignore it or block it out. And don’t struggle with it,
either. Allow it to play on in the background, acknowledging it’s there—
and focus your attention on what you’re doing.”

BUT I WANT TO GET RID OF THESE

THOUGHTS!
Suppose a client says, “But can’t I get rid of these thoughts?” We
may reply, “I’m guessing you’ve tried that already. What are some of the
methods you’ve used?” We then quickly elicit four or five of the
strategies they’ve employed to try to get rid of these cognitions (e.g.,
drugs, alcohol, positive thinking, distraction). Then we say, “So all these
methods work in the short term to make those thoughts go away—but
they soon come back again, right?”
We could follow that with some brief psychoeducation about
neuroplasticity, explaining that the brain can’t delete old neural
pathways; it can only lay down new ones on top of the old ones. (And if
clients have previously tried disputing their thoughts, we can point out:
“Even when you know, logically and rationally, that your thoughts aren’t
true, that doesn’t stop them from coming back, right?”) We may
continue:
Therapist: Unfortunately, there’s no delete button in the brain.
There’s no way to eliminate deeply entrenched thinking
patterns. It’s like, if you learn to speak Chinese, you
won’t eliminate English; you’ll have English and
Chinese. So we can’t subtract old patterns of thinking
—but we can add new ones. So for example, when “I’m
a loser” pops up, we can go, “Aha. There’s the ‘loser
theme’ again.”

Homework
For homework we may suggest:
Therapist: Like any new skill, this requires practice. So I’m
going to suggest a few things that I think would be
really helpful, if you could do them on a daily
basis.
Client: Okay.
Therapist: So first thing is, throughout the day, there’ll be
lots of times you get hooked. That’s a given. The
moment you realize it, see if you can unhook
yourself. So step one is to notice what’s hooking
you and then use the phrase… (Therapist
specifies the defusion phrase they have practiced
in session [e.g., “I’m having the thought that…” or
“Thanks, mind!”]) Often noticing and naming it will
unhook you, at least a bit. But if you’re still quite
hooked, the second step is to look at these
thoughts in terms of towards and away moves.
Ask yourself, “If I obey these thoughts, or give
them all my attention—where will that take me?
Towards or away from the stuff that really matters
to me?” And if that’s still not enough, if you’re still
 hooked, the third step is to drop anchor. How does
that sound to you?

EXTRA BIT In Trauma-Focused ACT: The Extra Bits chapter

ten, you’ll find (a) three worksheets: “Twelve Key Themes,” “Big
Six,” and “Relationship Roadblocks”; (b) Checklist for Common
Away Moves; (c) Caveman Mind Metaphors; (d) a link to a
humorous YouTube video on “Thanking Your Mind”; and (e) an
exercise on writing a compassionate letter to your mind.

Takeaway
The five main strategies we’ve covered in this chapter—notice, name,
normalize, purpose, and workability—are simple and practical. We can
combine them in many different ways to start shaping defusion skills
right from the first session.
Metaphors for defusion—such as Hands as Thoughts—are useful,
but they don’t build new skills. We need to follow them with active
skills-building exercises, which we practice in session and encourage as
homework.
 CHAPTER ELEVEN.

Heavy Lifting

In the last chapter we looked at quick, simple defusion techniques based

on noticing, naming, normalizing, purpose, and workability. Now we’ll
look at some more challenging skills and special considerations for
trauma. But first, let’s discuss a very important topic: cognitive
flexibility.

Cognitive Flexibility
If I had a dollar for every time I’ve heard someone say, “ACT doesn’t
change your thinking,” then I’d probably spend it all on chocolate. (And
believe me—it would be A LOT of chocolate!) The thing is, ACT does
change our thinking—dramatically. It changes the way we think about
our minds, our bodies, our thoughts, our emotions, how we want to live,
who we want to be, why we do what we do, what matters to us, and so
on.
However, ACT doesn’t achieve this by challenging, disputing,
disproving, or invalidating thoughts. Nor does it encourage people to
avoid, suppress, distract from, or dismiss their thoughts. ACT helps
people to change their thinking through (a) defusing from unhelpful
cognitions and cognitive processes and (b) developing new, more
effective ways of thinking, in addition to their other cognitive patterns.
As mentioned earlier, there’s no delete button in the brain. We can add
new ways of thinking, but we can’t subtract old ones.
 So, above and beyond fostering cognitive defusion, ACT actively
cultivates cognitive flexibility. ACT practitioners actively encourage,
model, and teach effective cognitive processes such as flexible
perspective taking, reframing, compassionate self-talk, values-based
problem solving and strategizing, motivational self-instruction,
examining behavior in terms of workability, nonjudgmental labeling of
thoughts and feelings, and so on.
These new ways of thinking are not to help people control their
feelings, but rather to develop psychological flexibility. So, for example,
in some models, a therapist may ask, “Is there another way you can think
about this?” And typically, the aim of such a strategy is to reduce
emotional distress. In ACT we may ask something similar, but with a
different aim: to foster values-based action: “Is there another way you
can think about this that might help you to deal with it more effectively
—more like the person you want to be?”
So, next time you hear someone claim that ACT “doesn’t change
your thinking,” you know what to say: “Buy Russ Harris some
chocolate!” Now, let’s take a look at some other methods of defusion.

Going Further with Defusion

There are countless methods for fostering defusion, beyond the simpler
techniques we’ve covered so far. I’ll share some of my favorites below.

Observing the Flow of Thoughts

Many defusion practices train clients to observe the ongoing flow of
their thoughts, without getting pulled into it. (These are also good
practices to help develop self-as-context, or the noticing self, because
they facilitate a sense of being “the observer” of your thoughts.) We
might introduce them as follows:
Therapist: When we’re ruminating, worrying, obsessing, or
just dwelling and stewing on stuff, we miss out on
 a lot, right? We can’t focus, we can’t engage in
what we’re doing. It’s like our thoughts are a
raging river, and we get pulled into it and we can’t
get back out. Do you relate to that?
Client: Yeah. Happens all the time.
Therapist: So it’s really useful to learn how to step back
from that river and watch it flow on by, without
getting pulled into it. This is basically the antidote
to worrying and ruminating. We can’t stop these
thoughts from arising, but we can learn to let them
float on by without getting swept away by them.
Leaves on a Stream (Hayes et al., 1999) is a popular ACT exercise
for observing the flow of your thoughts. You visualize a gently flowing
stream with leaves on the surface of the water, and imagine placing your
cognitions onto the leaves and letting them float on by. (For a recording
and script, see Extra Bits.) Common variants include clouds floating
through the sky, waves rising and falling in the ocean, and trains pulling
into and out of a station.
However, because exercises like this typically require sitting still
and closing your eyes to visualize, we can modify them for two groups
of clients: (a) those who find visualization hard or impossible
(technically known as “aphantasia”), and (b) those who tend to “drift
off,” fall asleep, have flashbacks, or dissociate during eyes-closed
exercises.
For both groups, a good alternative is Hearing Your Thoughts
(Harris, 2018). In this exercise, with your eyes open and fixed on a spot,
you “listen in” to your mind; you notice your thoughts as if listening to a
voice speaking, paying curious attention to auditory qualities such as
volume, pitch, tone, speed, and emotion. (For a recording and script, see
Extra Bits.)
For homework, you might suggest, “Practice this for five minutes
twice a day, or ten minutes once a day. And it’s also a great exercise to
do in bed, when you’re finding it hard to sleep.”
Getting Out of the River
When clients keep worrying, ruminating, or obsessing, it’s useful to
practice “getting out of the river” of repetitive negative thinking (an
exercise inspired by Wells, 2009).
Therapist: The idea here is to learn how to recognize when
you’ve fallen into the river—and how to get
yourself back out of it. So basically, the idea is that
you start worrying now, as much as you can, and
really get caught up in it. And then, every twenty
seconds, I’m going to press pause and get you to
stop for ten to twenty seconds. And then we’ll go
again. We’ll do six rounds, about three to four
minutes in total—is that okay?
Client: Yeah. Okay.
Therapist: Great. We’ll ease into it. We’ll start off with
daydreaming and then we’ll move on to worrying.
We now ask the client to daydream about something, like a book,
movie, or exciting event; an issue they’re passionate about; or a
pleasurable memory. After twenty seconds of daydreaming, we say:
Therapist: And pause. And what is your mind saying right
now? (Client shares their thoughts.) Okay. So
there’s a choice now. One option is to jump back
into the river—but if instead of that you want to
stay present, how could you do that?
Client: Look around the room?
Therapist: Yup, so acknowledge whatever thoughts are
present…and at the same time notice what you
can see and hear…and have a stretch…and
notice you and me, working together.
Client: So this is pretty much dropping anchor?
 Therapist: Yeah, it’s a variant on the theme.
Client: Got it.
Therapist: Okay. So let’s go again, daydreaming for another
twenty seconds. (Therapist sits silently for twenty
seconds.) And pause. So what thoughts are
showing up now? (Client shares their thoughts.)
Okay, so again there’s a choice—those thoughts
are present right now, and you can either engage
with me or go back into the river. Just try engaging
for a few seconds. (Client does so.)
After six rounds of daydreaming—with a ten-second pause between
each—we debrief the exercise. The key point is, whenever we catch
ourselves daydreaming, we have a choice: jump back into the river, or
focus on and engage in something else. Note how each time the client
“gets out of the river,” the therapist prompts them to acknowledge the
thoughts that are present; if this step is omitted, the exercise is likely to
function as distraction.
Next, we say, “So now, let’s ramp up the difficulty.” This time, we
ask the client to worry or ruminate about a difficult issue, and we follow
the same steps: twenty seconds in the river—ten to twenty seconds to
engage (while acknowledging the thoughts that are present)—then
repeat; again, for six rounds (three to four minutes in total). After this,
we debrief, emphasizing that we all get repeatedly “pulled into the
river,” but we can, with practice, get better at realizing it and faster at
getting back out.
For homework, we suggest, “Practice this for three to four minutes
twice a day. Find a quiet place, sit down, and set a timer to go off at
twenty seconds. Then start worrying (or ruminating). Each time the bell
rings, pause: notice your thoughts; have a stretch; engage in the world.
Then reset for another twenty seconds.” We add, “Also, throughout the
day, whenever you find yourself swimming in that river, press pause.
Take at least ten seconds to stretch and look around, get a sense of where
you are, what you’re doing—and then make a choice: will you jump
back into the river, or focus on something else?”
 “Worry Time”
The popular concept of “worry time” fits very well with TFACT,
provided we modify it. The idea is that if you worry a lot, you put aside
five to fifteen minutes each day, at a specified time, during which you do
nothing but sit down and allow yourself to worry. For the rest of the day,
when worries pop up, you say to yourself, Not going to worry about this
now. I’ll do it in my worry time. To make this strategy ACT-congruent,
there are two tweaks:
A. When worries pop up, say to yourself, Thanks mind. I know
you’re trying to help. And I’ll tackle this later in my worry time.
For now, I have to focus on other things. So by all means, keep
generating those worries—but just know, I can’t give them my
attention right now.
B. When you get to the “worry time,” don’t passively sit there and
allow yourself to worry; instead, respond to your worries
effectively. Either practice observing the flow of your worries or
getting in and out of the river; or tease out values from beneath the
worries, and use them to create an action plan (see chapters fifteen
and sixteen).
This strategy works well in conjunction with the defusion methods
above—and we can also use it for ruminating and obsessing.

The Big Three: Write; Move; Expand

Awareness
Three techniques are especially useful for tricky, sticky fusion: writing
thoughts down, physical movement, and expansive awareness. (And
again, we can adapt these methods for all private experiences: emotions,
urges, memories, physical sensations, and so on.)
 Writing Thoughts Down
Writing thoughts down is a powerful method for defusion; seeing
them in black and white creates a sense of distance, separation, or
“stepping back.” Either party can do the writing, but it’s often more
engaging for clients if they do it themselves. (If working via telehealth,
both client and therapist have a pen and paper, and we explain: “So you
write this down at your end, and I’ll write the same at my end.”)
The gist of this intervention is: So there are your thoughts; you can
see them, in black and white. But they don’t have to control what you do.
So what are you going to do next? In the transcript below, the client is
fused with hopelessness.
Therapist: Do you notice how often these thoughts keep
showing up? Would it be okay if I jot some of them
down, so we can have a look at them?
Client: Sure.
Therapist: Okay. (Speaking the client’s thoughts aloud while
simultaneously writing them down on a large sheet
of paper.) “This is a waste of time.” “There’s
nothing I can do.” “It’s pointless.” “It’s too late.” “My
life is fucked.” (Gives the paper to the client.) So
those thoughts keep cropping up, over and over,
right?
Client: Yeah.
Therapist: So I’m curious about what you’re going to do
next.
Client: What do you mean?
Therapist: Well (pointing to the paper), those thoughts are
here, right? You don’t like them, you don’t want
them—but here they are. And the question is: what
will you do next? With those thoughts present, you
can do things that make your life better—or you
 can do things that make it worse. For example,
suppose you wanted to make this therapy session
go really badly, what could you do?
Client: I suppose I could just not listen to you.
Therapist: Yeah. That’s one option. Anything else you could
do—you know, if you really wanted to make this
unpleasant?
Client: I suppose I could insult you.
Therapist: Yeah. Or grab some books from the bookcase
and throw them at me. Or break the window. Or
set fire to the carpet. Any other ideas?
Client: Steal your wallet?
Therapist: Yep, exactly. Or you could even just refuse to talk
to me. On the other hand, if you wanted this to be
a pleasant and productive session, what are some
things you could do?
Client: Err, I’m not sure.
Therapist: Well, how about what you’re doing right now?
You’re engaging, talking to me, listening, thinking
about the questions I’m asking you, being polite
and cooperative…
Client: Oh, right—yeah, I see.
Therapist: So you can choose to keep doing more of that—
which will keep the session flowing—or do some of
the other things, which will bring it to a crashing
halt.
Client: Right.
Therapist: So which are you going to choose?
 Client: (playfully) Don’t worry—I’m not going to steal your
wallet.
Therapist: (chuckling) So here’s the thing: in each moment
there’s a choice point. We can choose to do
something that makes life worse—or makes it
better—even when difficult thoughts and feelings
are present. And I don’t expect your mind to agree
with me. I expect your mind to go, “That’s bullshit!”
and say some of these things again (points to the
paper). Is it doing that?
Client: (playfully) How’d you know?
Therapist: (chuckling) Because that’s what minds do. And
your mind is never going to agree with me on this
—but the good thing is, it doesn’t have to. So let’s
not waste time trying to convince your mind. What
I predict is, throughout our work here, your mind’s
going to keep saying this stuff (points to the paper)
over and over again—here in the room and
outside it—and each time those thoughts show up,
there’s a choice point.
This intervention touches on ideas covered earlier, but the
physicality of the paper adds some “oomph!” (It also works well via
telehealth; after writing each thought down, we hold the paper up to the
camera so the client can see it.) This strategy is useful with any cognitive
content: reason-giving, rules, judgments, self-concept, core beliefs,
schemas, and so on. When we write these cognitions down and help
clients notice that they have choices—even though these difficult
thoughts are present—it’s a powerful experience.
And we can modify this strategy in many ways. For example,
suppose a client keeps problem hopping or getting hooked by worries
that pull them off topic:
Therapist: (noticing) Have you noticed how your mind
keeps jumping from one thing to another? It seems
 like your mind won’t give you any peace at all. As
soon as we focus on one issue, your mind pulls
you to another.
Client: Yeah, I know. I can’t help it. It never stops. There’s
so much going on.
Therapist: From where I’m sitting, it looks exhausting.
What’s it like for you, having your mind jerk you
around like that?
Client: Yeah, it is exhausting.
Therapist: (normalizing) Everyone’s mind does this at times.
(purpose) It’s like your mind wants to keep on top
of all these issues; doesn’t want you to forget
anything. (workability) The problem is, if you keep
letting your mind hook you this way, what
happens?
Client: I just keep worrying.
Therapist: Yeah, for sure. And if we let that happen in our
sessions, we’re not going to achieve very much.
So one of the most useful skills you can learn
here, to help you with X (mentions some of the
client’s therapy goals), is to recognize when you’re
getting hooked, distracted, and pulled off task—
and learn to unhook yourself from those worries
and refocus on the task at hand.
Client: Yeah, but look—these aren’t just “worries.” These
are real problems!
Therapist: You are right. They are real problems. Real,
challenging, stressful problems—things that you
need to deal with. And there’s an essential skill
you need, if you want to deal with them effectively.
Do you know what it is?
 Client: Er, no.
Therapist: It’s called “task-focused attention,” the ability to
stay focused on a task. And the task we have here
is to stick with one problem long enough to come
up with a strategy that you can take home after the
session and apply. So if we keep going off task, we
won’t get anywhere. So can we spend a bit of time
working on this skill?
The term “strategy,” as used above, could refer to any TFACT
intervention: a defusion or acceptance skill, a value, a goal, a step-by-
step action plan, and so on. Once clients understand the rationale for
task-focused attention, they are usually willing to practice it in session.
So we write down five to ten of the client’s main worries (i.e., the
thoughts that keep hooking them in session). Then we point to the paper
and say, “Each time these show up, there’s a choice point. We can stick
to the problem we’re working on and stay with it until we have a
strategy, or we can let these other things pull us off track.”
We then put the paper somewhere clearly visible (e.g., on the couch
beside the client, on the floor in front of them). Later in session, when
the client mentions other thoughts on the paper, we can say, “Do you
notice what your mind is doing right now? (pointing to the paper) That’s
right there, on the list. And now there’s a choice point—do we let this
pull us off track, or do we stay on course?”

PLACING THOUGHTS ON OBJECTS

If you’re not keen on writing thoughts down, you can instead invite
the client to imagine placing the thoughts on top of an object. For
example: “Can I ask you to imagine something? Imagine collecting all
those thoughts and placing them in a little pile on the couch, beside you.
Just on top of the cushion.” From there, the intervention is the same:
“Okay, so all those thoughts are in a pile, right there on the cushion. And
they’re not about to suddenly disappear. So now there’s a choice to
make…”
 Physical Movement
If a client starts to “freeze” in response to those thoughts on the
paper, we can say:
Therapist: Okay, so you seem to be locking up a bit there. Let’s
see if you can reverse that. Notice, the thoughts are
there, and at the same time, push your feet into the
floor…and straighten your back…and stretch out your
arms… (Therapist continues giving such instructions
until the client is freely mobile.)… So notice (pointing to
the paper), the thoughts are right there with you, but
they don’t control you; you can choose what actions
you take with your arms and legs, hands and feet…
Physical movement is useful for defusion because it helps us to
notice that difficult thoughts are present, but they do not have to control
our actions. The basic intervention (always preceded by lots of
normalizing and validating) is:
Therapist: Notice these thoughts (points or refers to the paper or
object, or speaks some of the client’s thoughts aloud)
are present…and also notice, they do not control your
arms and legs. Check it out for yourself; move them
around. You are in control of your actions.
From this point on, there are many options. We could invite the
client to stand and walk around, to stretch or shift position, to do a tai chi
or yoga move, to mindfully drink a glass of water, and so on.

Expanding Awareness
Expanding awareness in the presence of difficult thoughts and
feelings—without trying to distract from them—can facilitate defusion at
any point in any session. Clients have already been doing this when
dropping anchor, so we can readily play around with it and use it as an
“add-on” or alternative to any of the interventions above:
 Therapist: So notice those thoughts are here…and without
trying to ignore them or distract yourself, see if you can
expand your awareness…what else can you notice
here, in addition to those thoughts? (Therapist now
prompts client to notice what they can see, hear, touch,
and so on. After a minute or so, the therapist says…)
So there’s a whole lot going on in this moment—so
many things you can see and hear and touch—in
addition to all those thoughts. So the question is, how
much attention and energy do you want to invest in
these thoughts? If they’re telling you something useful
and important that’s going to improve your life, you
want to make good use of them. But if they’re not doing
that, how about you let them sit there, and put your
energy and attention into something more life
enhancing?

Playful Defusion
ACT is well known for playful defusion techniques, such as singing
thoughts, saying them in silly voices, or saying them extremely slowly
(Hayes et al., 1999). Naturally, we want to be cautious about using these
methods with trauma, because if we aren’t careful, they may come across
as dismissive or trivializing. So it’s arguably safer to hold such methods
back for later sessions, once clients are clear on the aims of defusion and
have practiced other techniques such as those described earlier.
“Playing with your thoughts” involves putting them into a new
context where you can readily recognize that they are constructs of
words or pictures; this neutralizes their power, making it easier to
unhook from them. Typically these methods highlight either the visual
properties of thoughts (i.e., “seeing” them), their auditory properties (i.e.,
“hearing” them), or both. The best way to learn these methods (in my
opinion) is to try them on yourself and notice what happens; you’ll likely
find that some work well, and others don’t. If you find one or two that
really help you to unhook, experiment with them over the next few days.
 However, if any technique makes you feel trivialized or mocked, then
don’t use it (and obviously, we’d say the same to our clients).

Playful Visual Techniques

On a piece of paper, jot down several of the thoughts that most
frequently hook you and distress you. For each technique below, select
which of these thoughts to work with, go step-by-step through the
exercise, and be curious about and open to whatever happens.

Thoughts on Paper
Write two or three distressing thoughts on a large piece of
paper.
Now hold the paper in front of your face and get absorbed in
those thoughts, for about ten seconds.
Next, place the paper on your lap, look around you, and
notice what you can see, hear, touch, taste, and smell.
Acknowledge the thoughts are still with you. Notice they
haven’t changed at all, and you know exactly what they are—
but does their impact lessen when you rest them on your lap
instead of holding them in front of your face?
Now on the paper, underneath those thoughts, draw a stick
figure (or, if you’re artistic, a cartoon character). Draw a
“thought bubble” around those words, as if they are being
thought by the stick figure. Now look at your “cartoon”: when
you see your thoughts like this, does it make any difference to
the way you relate to them?

Try this a few times with different thoughts and stick figures. Put
different faces on your stick figures—a smiley face, a sad face, or
one with big teeth and spiky hair. Draw a cat, a dog, or a flower with
those very same thought bubbles coming out of it. Does this change
the impact of those thoughts? Does it help you to see them as
words?

Computer Screen
You can do this exercise either in your imagination or on a computer.
First write (or imagine) your thought in standard lowercase black
text, on the computer screen. Then, play around with it. Change it
into different colors, fonts, and sizes, and notice what effect each
change makes. (Bold red uppercase letters may sometimes hook
people; if so, change to a lowercase pale pastel color.)
Then change the text back to black lowercase.
And now, play around with the formatting:

Space the words out, placing large gaps between

them.
Run the words together—no gaps between them—so
they make one long word.
Run them vertically down the screen.

Finally, put them back into normal formatting.

How do you relate to those thoughts now? Is it easier to see that
they are words?

Karaoke Ball
Imagine your thoughts as words on a karaoke screen. Imagine a
“bouncing ball” jumping from word to word across the screen. (If you
like, imagine yourself on stage, singing along.)
Repeat this several times, with different thoughts.
 Changing Settings
Imagine your thought in a variety of different settings. Take about five
to ten seconds to imagine each one, then move on to the next. See
your thought written:

in playful colorful letters on the cover of a children’s

book
as stylish graphics on a restaurant menu
as icing on top of a birthday cake
in chalk on a blackboard
as a slogan on a T-shirt

WORKING WITH IMAGES

We can adapt most of the methods above for images. For example,
you can imagine your images on TV, computer, and smartphone screens
—and play around with colors, size, contrast, saturation, and brightness,
or add text and subtitles. You can also visualize them in different
settings: on a book, postcard, or painting; on a billboard as you’re
driving past; or on the side of a kite, flying through the sky.

Playful Auditory Techniques

Now play around with the auditory properties of your thoughts and
notice what difference it makes. Does it help you to perceive them as
sounds, noises, or speech?

Silly Voices
Say your thought in a silly voice—either silently or out loud. (Out loud
is often more helpful, but obviously you need to pick an appropriate
time and place.) You might choose the voice of a cartoon character,
movie star, sports commentator, or someone with an outrageous
accent. Try several different voices and notice what happens.

Slow and Fast

Say your thought—either silently or out loud—first very slowly, then
at superfast speed (so you sound like a chipmunk).

Singing
Sing your thoughts—either silently or out loud—to the tune of “Happy
Birthday.” Then try it with a couple of different tunes.

Smartphone Apps
Speak your thought aloud into a smartphone app that plays it back,
humorously altering your voice.
For example, the “Super Voice Changer” app will play your
speech back in the voice of Darth Vader, Wall-E, Donald Duck, and
many others. And the “AutoRap” app turns whatever you say into a
rap song, with a drumbeat and music in the background.

Create Your Own Techniques

Now invent your own techniques. Put your thought in a new context
where you can “see” it or “hear” it. You might visualize your thought
painted on a wall, printed on a book, embroidered on the tutu of a ballet
dancer, carved into a tree trunk, trailed on a banner behind an airplane,
tattooed on a bicep, or inked in beautiful italics on a medieval
manuscript. You could paint it, draw it, or sculpt it. You could imagine it
jumping, hopping, or dancing; or visualize it moving down a TV screen,
like the credits of a movie. Alternatively, you might imagine hearing
your thought recited by a Shakespearean actor, playing on a podcast,
emanating from a robot, or sung by a rock star. So be creative, invent
your own, and encourage your clients to do likewise.

Homework
We may suggest clients practice playful defusion whenever they get
the opportunity. It’s often most useful when they’re finding it hard to
unhook. So, for example, if they’ve already used other defusion
methods, and they’re still hooked, they can pick one of the thoughts
that’s most difficult and start playing around with it. Then they can pick
another, and so on.

Defusion Likes Company

All six core ACT processes are important; they all interconnect and
reinforce each other. And sometimes therapists get stuck because they
over-rely on one process while underutilizing others. Consider a client
who has a core belief like “I’m worthless and I don’t deserve to live,”
stemming back to horrific childhood trauma, and they are repeatedly
fusing with it, triggering serious self-destructive behavior. In this case,
defusion skills alone are unlikely to be enough. Defusion will be helpful,
for sure—but we’ll also need to bring in self-compassion, values,
acceptance, dropping anchor, and so on.
I mention this because therapists sometimes complain, “I’ve tried
lots of defusion, but we’re not getting anywhere.” This indicates the
need to bring in other parts of the model. As an example, let’s consider
fusion with rules—a major factor in issues such as fawning (i.e., extreme
“people pleasing”) and perfectionism.
When clients are fused with rules such as “I have to do it perfectly;
I mustn’t make mistakes” (perfectionism) or “I have to keep everyone
happy; my needs don’t matter” (fawning), three strategies are especially
important and useful:
 1. Defuse from the rule (notice, name, normalize, purpose,
workability).
2. Find the underlying values and explore flexible ways of living
them.
3. Make room for the inevitable discomfort and be kind to yourself.

Let’s unpack these strategies a bit.

Defuse from the rule (notice, name, normalize, purpose,

workability). By now, you’ve read enough about noticing, naming, and
normalizing, so let’s skip straight to purpose and workability.
Perfectionistic rules can serve many useful purposes: they can motivate
you to work hard, be productive, and do good-quality work; protect you
from making mistakes or underperforming; gain you praise, approval, or
respect; help you achieve important goals; and boost your self-image as
efficient, productive, reliable, a “performer”—while helping you escape
a negative self-concept such as “I’m unworthy.”
Similarly, people-pleasing rules can motivate you to look after and
take care of others; protect you from rejection or hostility; gain you
approval, affection, or gratitude; help you avoid conflict and increase
positive interaction in relationships; and boost your self-image as caring,
kind, helpful, a “giver”—while also helping you escape a negative self-
concept such as “I’m unlovable.”
So after uncovering, normalizing, and validating these benefits, we
may summarize: “There are real payoffs to following these rules; this is
your mind protecting you from stuff you don’t want, and helping you to
get things you do want.”
From there we can turn to workability: We help clients to recognize
that when they follow these rules rigidly, treat them as laws that must
always be obeyed, the costs are usually significant: chronic stress, high
anxiety levels, exhaustion, compulsive rituals, lack of motivation, or
depression. In addition, in the long term, following these rules usually
reinforces negative self-concepts. For example, following perfectionistic
rules about achievement reinforces the belief “I’m only worth something
when I’m getting good results; when I’m not successful, I’m worthless.”
Following rules about always pleasing others reinforces “I’m not
important; my needs don’t matter.”
Once clients recognize these long-term costs, we can consider more
workable options. We may say, “There are many benefits to following
this rule, and obviously you don’t want to lose those. So what if there’s a
way to keep most of those benefits while also starting to bend those rules
a little?” This naturally leads into the next strategy…

Find the underlying values and explore flexible ways of living them.
With some gentle, compassionate digging, we will always find values
beneath these rigid rules. With perfectionism, we usually find values
such as efficiency, reliability, competence, and responsibility. With
people pleasing, we tend to find values such as self-protection, giving,
caring, and helping. The aim is to then live by these values flexibly—
acting on them in ways that enhance well-being and improve quality of
life.

Make room for inevitable discomfort and be kind to yourself. When

people start to bend or disobey rigid rules, all sorts of uncomfortable
thoughts and feeling show up: fear, anxiety, reason-giving, and so on.
This is inevitable; when we step out of our comfort zone, we get
discomfort. So to handle all those difficult thoughts and feelings,
acceptance and self-compassion skills are essential.
Obviously, there’s more to these issues than the strategies briefly
outlined above. For example, we usually need to bring in self-as-context
and self-compassion to work with the client’s self-concept. Also, rigid
rule following is frequently accompanied by harsh self-criticism—and
some clients (especially those with perfectionistic tendencies) will say
this helps motivate them to do things that matter to them; we address this
common sticking point in chapter fourteen.
The key point here is that while defusion is helpful in itself, it’s far
more potent when combined with other core processes, so be sure to
bring them in if you’re not making headway. (And if you’re hungry for
more on working with rigid rules, see the sections “I Don’t Deserve
Kindness” in chapter fourteen, “Clarifying Motivation”—which is all
about “people pleasing”—in chapter fifteen, and “Defusion from the
Rule ‘Don’t Trust’” in chapter twenty-eight.)

EXTRA BIT In chapter eleven of Trauma-Focused ACT: The

Extra Bits (downloadable from Free Resources on
http://www.ImLearningACT.com), you’ll find a script and audio
recording of “Hearing Your Thoughts”; a client handout on
“Playing With Thoughts”; and a link to an e-book called
Preempting Your Mind, which goes further with some of the
strategies mentioned above.

Takeaway
Exercises such as Hearing Your Thoughts, Leaves on a Stream, and
Getting Out of the River are powerful antidotes to rumination, worry, or
the myriad of other ways we get “lost in our thoughts.” Playful defusion
techniques can also be effective—although we need to be cautious when
using them, particularly with clients dealing with trauma-related issues,
to prevent invalidation. As for writing thoughts down, physical
movement, and expanding awareness: keep these at the top of your
toolkit because they can facilitate defusion from just about anything
(especially when combined with dropping anchor).
 CHAPTER TWELVE.

Leaving the Battlefield

The ongoing war with unwanted thoughts and feelings takes its toll. Like
combat in the real world, the battle with our inner experiences is
exhausting—and comes with heavy casualties. And while we’re all
experientially avoidant to some extent (yes, it’s normal, folks!), the more
extreme this tendency, the more problems it creates.
Unfortunately, to the client, these unwanted inner experiences truly
are the enemy, and their only two options are to fight them or run away.
To open our clients to a third option—acceptance—we need to
undermine their attachment to the other two. We do this through a
process called…

Creative Hopelessness
Creative hopelessness means creating a sense of hopelessness in the
agenda of emotional control: I must control how I feel; I have to get rid
of these bad thoughts and feelings and replace them with good ones. As
you know, this agenda fuels much unworkable action: self-harming,
avoidance of intimacy, social withdrawal, and so on. Through gently and
compassionately undermining this agenda, we hope to open clients to an
alternative: the agenda of acceptance.
Creative hopelessness (CH) is rarely a once-off intervention;
usually we need to revisit it several times. (But it gets quicker and easier
each time around.) Like anything in TFACT, there are numerous ways of
doing it, but all CH interventions basically boil down to three questions:
What have you tried? How has it worked? What has it cost?

What Have You Tried?

The first CH question is What have you tried so far to get rid of
these difficult thoughts and feelings?
For example:
Client: I’m sick of feeling this way. I want to feel normal
again.
Therapist: Of course you do. These feelings have been
jerking you around for a long time.
Client: So how do I get rid of them?
Therapist: Well (referring back to informed consent), you
might recall, a big part of our work here is about
learning new skills to handle difficult feelings more
effectively—how to take the impact and power out
of them, so they can’t keep jerking you around.
Client: Yeah, that’s what I want. Let’s do that.
Therapist: Okay, but the thing is—I don’t want to waste time
doing things you’ve already tried. I want to give
you some brand new tools and strategies, radically
different from what you’ve done before. So can we
take a few moments just to get clear on what
you’ve already done? How have you tried to get rid
of these thoughts and feelings?
At this point, we will usually need to prompt clients to help them
remember all the strategies they have been using. A simple method for
doing this is “Join the DOTS” (Harris, 2009a). The acronym DOTS
stands for D–distraction, O–opting out, T–thinking, and S–substances
and other strategies. (See Extra Bits for a “Join the DOTS” worksheet.)
 Throughout this process, we model openness, curiosity, and
compassion. And we never judge any of these strategies as “good,”
“bad,” “right,” “wrong,” “positive,” or “negative”; we look at them
purely in terms of workability. So, suppose a client, referring to a
behavior they’ve just mentioned, asks, “Is there something wrong with
doing that?” We’d immediately reply, being absolutely genuine, “No, not
at all. I’m just trying to find out what you’ve already tried—to make sure
that we do something different.”
Generally, two to three minutes is enough time for each category of
DOTS: eight to twelve minutes in total. (As a general rule, the less
avoidant the client, the less time needed.)

D–DISTRACTION
Most clients have many different methods of distracting themselves
from unwanted thoughts and feelings, but often they don’t realize it. So
we ask them, “Have you ever tried to distract yourself from these
thoughts and feelings?” If necessary, we can prompt them: “Have you
tried watching television? Listening to music? Getting out of the house?
Keeping busy? Playing computer games? Reading books?”

O–OPTING OUT
“Opting out” is everyday language for overt avoidance: avoiding
things in the world around you, such as people, places, objects, events.
We may say, “Most of us try to escape difficult feelings by opting out of
the difficult things that trigger them. I’m wondering, have you tried
staying away from situations, people, places, events, activities—stuff
that tends to bring up these uncomfortable thoughts and feelings? What
kind of stuff have you been procrastinating on? What have you given
up? What are you staying away from?”

T–THINKING
Here we may say, “Most of us try at times to think our pain away;
have you ever tried that? Any particular thinking strategies you’ve found
helpful?” We can then list some common thinking strategies, for
example: “Have you tried thinking of people who are worse off than
you? How about positive thinking? Ever tried disputing your thoughts,
trying to prove them false? Or pushing thoughts out of your head? Or
just ‘not thinking about it’? Ever tried positive affirmations?”

S–SUBSTANCES AND OTHER

STRATEGIES
Next we may say, “Almost all of us at times put substances into our
body to make ourselves feel better—whether that’s drugs and alcohol or
chocolate and coffee. Have you ever tried doing that? What sorts of
substances?” Here, clients rarely need prompting—but if they do, we
may ask, “Have you ever tried marijuana or alcohol? Nicotine? Tea or
coffee? Sugar? Chocolate? Pizza? Ice-cream? Recreational drugs?”
(Therapists are sometimes thrown when clients mention prescription
medications: for tips on this, see Extra Bits.)
Finally we ask, “Are there any other strategies you’ve ever used to
get some relief from these feelings? Take your mind off them, or escape
from them for a little while?” We may specifically ask about strategies
from self-help books or previous models of therapy, or suggestions from
friends and family, or problematic behaviors the client mentioned earlier
(e.g., self-harming).

How Has It Worked?

Next we normalize and validate the client’s strategies, then
compassionately look at the long-term consequences:
Therapist: Most of these strategies you’ve mentioned are
extremely common—almost everyone uses them
to some extent. And they work pretty well in the
short term. They give you some relief, reduce the
pain, make you feel a bit better. But what happens
in the long term?
 Client: What do you mean?
Therapist: Well, in the long term, do any of these strategies
work permanently—so these difficult thoughts and
feelings are gone, for good? Never coming back?
Client: Obviously not, or I wouldn’t be here.
Therapist: Right. And that’s a really important point. You’ve
been working hard at this for a long time—I mean,
really hard—and all these things you’ve been
doing, they kind of work short term, but long term,
this painful stuff keeps on coming back.

What Has It Cost?

The third CH question is the clincher. With great compassion, we
say, “Most of us find that quite a few of these strategies have long-term
costs. I’m wondering, have you found that at all? Any negative
consequences—such as costs to your health or well-being, or
relationship problems, work problems, financial costs?” Then we take
several minutes to help the client connect with the true costs of over-
relying on these strategies.
At this point, a quick reminder: mild experiential avoidance is
rarely a problem and can even be life enhancing, but high levels come
with significant costs. So we now uncover those costs in each category
of DOTS. For example: “You’ve mentioned a few distraction strategies
there; have there been any costs of using those? Any problems with
relationships? Health issues? Work problems? Financial problems?”
For each category of DOTS, there are specific costs we want to
highlight:

Distraction: “Has this ever resulted in a sense of wasted time or energy

—as if you’re not really spending your time on things that are truly
important and meaningful to you? Or a sense of wasted money, or
energy? Or missing out on life?”
Opting out: “Has this ever resulted in missed opportunities? Or a sense
of missing out on people, places, situations, or activities that are
important and meaningful? Or a sense that life is getting smaller?”

Thinking strategies: “Do you ever spend a lot of time caught up in your
thoughts? Maybe missing out on life? Or finding it hard to focus? Ever
been awake at three in the morning thinking this through?”

Substances: “Could these be damaging your health in any way? Are

there any other costs—financial or work maybe? Any effects on your
relationships?”
If we can identify ten to fifteen costs (in total), that’s usually
enough; typically that takes three to six minutes.

You’ve Worked Hard!

We now want to validate the client’s steadfast effort:
Therapist: You’ve really worked hard at this. You have tried
and tried for a long, long time to avoid and get rid
of these painful thoughts and feelings. No one can
call you lazy! You’ve put in a lot of effort. And no
one can call you stupid; we all use these
strategies. We all distract ourselves; we all opt out
or back off from the difficult stuff; we all try to think
our way out of pain; and we all use substances of
some form or another, even if it’s just aspirin or
chocolate. And why? Because everyone around us
recommends these strategies—friends, family,
doctors, health and fitness magazines… This is
the conventional wisdom, right? It’s the same
advice from everybody: “Make these thoughts and
feelings go away!”
Client: Are you saying that’s wrong?
 Therapist: Not at all. I’m saying, you and me and everyone
else I know, we’ve all grown up in a culture that’s
bombarded us with this message our whole lives.
So it’s completely natural that you’re doing all this
stuff. And what keeps it going is the short-term
payoff; because short term, it gives you relief. But
long term, it’s costing you. Some of these
strategies have drawbacks. They’re taking a toll. I
mean, in the long term, are they really giving you
the sort of life you want?

Practical Tip
Sometimes a client may say, “So am I supposed to just suck it
up and get on with it?” or “So what do I do; just give up?”

We could reply, “No, not at all. I’m guessing you’ve already tried
that? (Client says yes.) And did it work to give you the sort of life
you want? (Client says no.) Okay, so, that’s yet another strategy
we won’t use.”

How Are You Feeling?

By this point, most clients will have had an emotional reaction:
commonly sadness, anger, or anxiety. But this is often mixed with relief,
because we are powerfully validating the client’s experience: we’re
acknowledging just how hard they have been working (often following
well-meaning advice) and the painful fact that in the long term, it’s not
giving them what they want.
To gauge their reaction, we ask, “I’m wondering how you’re feeling
right now. Like, for a lot of people, this process brings up some sadness
or anxiety or anger—anything like that for you?” And whatever
emotions they report, we normalize: “That’s a completely natural
reaction. You’ve been stuck in a vicious cycle for a long time, through
no fault of your own—and it’s painful to face that. It hurts.” (And of
course, if the emotions are overwhelming, we drop anchor; or if the
client fuses with harsh self-judgment—“I’m such a loser. This just
confirms how stupid I am”—we segue into defusion. But these reactions
are uncommon.)

Are You Open to Something Radically

Different?
Now that we’ve identified the costs of war, it’s time to suggest
leaving the battlefield. We may say, “You’ve been trying hard for a long
time to get rid of this stuff—and it’s really taking a toll on you. So I’m
wondering if you’re up for something different. The skills I’d like to
introduce you to are completely and radically different from everything
else you’ve mentioned. A brand new way of responding to your feelings.
Would you be up for that?”
Many clients will say yes; some will say they don’t know; and a
few will ask anxiously, “What does it involve?” Whatever they say, we
reply, “Well, let me take you through a little exercise to help you
understand what’s involved.” We then move on to…

Dropping the Struggle

Following creative hopelessness, we introduce a metaphor about
dropping the struggle with difficult thoughts and feelings, and this
signposts the route to acceptance. My favorite metaphor for this purpose
is Pushing Away Paper (chapter two) because it quickly highlights the
costs of experiential avoidance and the benefits of acceptance. At the end
of the exercise, the paper is still present, emphasizing this is not a way to
get rid of unwanted thoughts and feelings. Nor is it a way to dismiss or
ignore them; the exercise highlights that painful emotions hold valuable
information, but we can’t utilize it if we’re busy pushing them away.
If Pushing Away Paper is inappropriate (e.g., because the client or
therapist has neck or shoulder problems), a good alternative is the
Struggle Switch metaphor (Harris, 2007).

The Struggle Switch

Therapist: Imagine that at the back of our mind is a
“struggle switch.” When it’s switched on, it means
we’re going to struggle against any physical or
emotional pain that comes our way; whatever
discomfort shows up, we’ll try our best to get rid of
it or avoid it.
Suppose what shows up is anxiety. (We modify
this to fit the client’s issue; instead of anxiety it
may be anger, sadness, painful memories, urges
to drink, and so on.) If my struggle switch is on,
then I absolutely have to get rid of that feeling! It’s
like, Oh no! Here’s that horrible feeling again. Why
does it keep coming back? How do I get rid of it?
So now I’ve got anxiety about my anxiety.
In other words, my anxiety just got worse. Oh,
no! It’s getting worse! Why does it do that? Now
I’m even more anxious. Then I might get angry
about my anxiety: It’s not fair. Why does this keep
happening? Or I might get depressed about my
anxiety: Not again. Why do I always feel like this?
And all of these secondary emotions are useless,
unpleasant, unhelpful, and a drain on my energy
and vitality. And then—guess what? I get anxious
or depressed about that! Spot the vicious cycle!
But now suppose my struggle switch is off. In
that case, whatever feeling shows up, no matter
how unpleasant, I don’t struggle with it. So anxiety
shows up, but this time I don’t struggle. It’s like,
Okay, here’s a knot in my stomach. Here’s
tightness in my chest. Here’s sweaty palms and
shaking legs. Here’s my mind telling me a bunch
of scary stories. And it’s not that I like it or want it.
 It’s still unpleasant. But I’m not going to waste my
time and energy struggling with it. Instead I’m
going to take control of my arms and legs and put
my energy into doing something that’s meaningful
and life enhancing.
So with the struggle switch off, our anxiety level
is free to rise and fall as the situation dictates.
Sometimes it’ll be high, sometimes low;
sometimes it will pass by very quickly, and
sometimes it will hang around. But the great thing
is, we’re not wasting our time and energy
struggling with it. So we can put our energy into
doing other things that make our lives meaningful.
But switch it on, and it’s like an emotional
amplifier—we can have anger about our anger,
anxiety about our anxiety, depression about our
depression, or guilt about our guilt. (At this point,
we check in with the client: “Can you relate to
this?”)
Without struggle, we get a natural level of
discomfort—natural, given who we are and what
we’re doing. But once we start struggling, our
discomfort levels increase rapidly. Our emotions get
bigger, and stickier, and messier; hang around
longer; and have much more impact on our behavior.
So if we can learn how to turn off that struggle
switch, it makes a big difference. And what I’d like to
do next, if you’re willing, is show you how to do that.

Other popular metaphors for dropping the struggle include “Tug of

War with a Monster” and “Struggling in Quicksand” (Hayes et al., 1999;
both described in Harris, 2019, ACT Made Simple, 2nd edition, pages
106–108). All these metaphors convey the concept of acceptance: what’s
involved, how it works, and the rationale behind it. But that’s just the
start. The next step is to actively teach acceptance skills, which we’ll
cover in the next chapter.
 EXTRA BIT In Trauma-Focused ACT: The Extra Bits, chapter
twelve, you’ll find (a) the “Join the DOTS” worksheet, (b) what to
do when clients mention prescription medications, and (c) a link
to a YouTube animation of the Struggle Switch metaphor.

Takeaway
Creative hopelessness undermines the agenda of emotional control by
looking at it in terms of workability. This paves the way for acceptance.
As long as we are kind and understanding, clients find this process
validates their experience: they’ve tried hard to control the way they feel,
but it’s not working over the long term and life is getting worse.
We first explore three basic questions: What have you tried? How
has it worked? What has it cost? We then acknowledge how hard they
have worked, compassionately validate the client’s emotional reaction,
and ask whether they are open to trying something different. If the
answer is yes, we follow up with a metaphor about dropping the
struggle, which sets the stage for actively learning acceptance skills.
 CHAPTER THIRTEEN.

Making Contact, Making Room

Welcome to what is arguably the hardest part of the entire ACT model:
accepting painful private experiences. (And please note: although we
will focus on emotions, these principles apply to any private experience
—including numbness.) But first, a friendly caution. I recommend you
don’t use the word “acceptance” with clients because most people think
it means tolerance, giving up, resignation, putting up with it, or
admitting defeat. Better terms include making room, opening up,
acknowledging and allowing it, dropping the struggle with it, making
peace with it, stepping out of the battle with it, holding it
lightly/gently/kindly, softening up around it, expanding around it,
breathing into it, letting it freely flow through you, and leaning into it.
Also, many ACT protocols use the term “willingness” as an alternative
to acceptance: the willingness to have your thoughts and feelings, the
willingness to make room for them, the willingness to let them be as they
are.
As you read on, you’ll discover that much of this chapter actually
focuses on exposure, a concept that overlaps heavily with acceptance.

The Four As of Acceptance

I think of acceptance in terms of the “four As”: Acknowledge, Allow,
Accommodate, Appreciate. Let’s explore these through a metaphor.
Suppose one day your doorbell rings, and you open it—only to find, to
your great surprise, it’s your Uncle Tim. He’s an intensely annoying (but
totally harmless) relative.
Your first step is to acknowledge that he’s there: “Oh! Hi, Uncle
Tim!”
Now you don’t like Uncle Tim; you sure as hell didn’t invite him—
but hey, here he is. So you decide to allow him inside: “Come on in,
Uncle Tim.”
Your next step is to accommodate him; you take him to the kitchen,
offer him a chair, give him a cup of tea.
Now Uncle Tim starts doing all his usual annoying stuff—telling
jokes you hate and stories you find boring, and at first you’re not really
listening. But suddenly you remember—you’ve been struggling with this
big problem, and Uncle Tim just happens to be an expert in that area. So
you ask him about it, and you wait attentively, and you listen carefully,
and lo and behold, he starts giving you golden information about how to
address this big problem, valuable insights you can apply to good effect.
So now, you’re starting to appreciate Uncle Tim.
As you read through this textbook, I hope and trust you’ll notice the
four As of acceptance—acknowledge, allow, accommodate, appreciate
—cropping up repeatedly. And although we don’t have to follow them in
that order, as it happens, a lot of the time we do. With unwanted painful
emotions, we first acknowledge them and allow them to be present. Then
we go a step further, to accommodate them: opening up and making
plenty of room for them.
And then we go on to appreciate them—for their help and
guidance. One aspect of this is appreciating the positive functions of
painful emotions; they’re not there to make our lives miserable; they
serve a valid purpose. Another aspect is tuning into them and extracting
their wisdom. For example, we may ask: “What does this emotion tell
you that you really care about, or need to face up to, or need to do
differently?” Exploring our emotions in this way usually connects us
deeply with our values and needs.
 In addition, we can sometimes harness the energy of an emotion.
For example, at times we can channel the energy of anger into a
constructive fight for justice, or the energy of anxiety into our
performance. Other emotions, such as sadness, have more of a “slowing
down” effect, lowering our energy levels; at times, we may be able to
channel this into restful mindfulness practices, or creative or self-
soothing activities.

Tolerance and Pseudo-acceptance

Acceptance is different from tolerance. (Would you rather your
friends “tolerated” you or “accepted” you?) Tolerating an emotion means
that you’re not putting effort into avoiding it, but your agenda is still I
want it gone. Tolerance often manifests as “pseudo-acceptance”: using a
so-called “acceptance technique” with the hope it will make unwanted
thoughts and feelings go away. (You’ll recall we know when clients are
doing this because they complain, “It’s not working.”)
Also look out for comments like “I should accept it” or “I guess I
just have to accept it.” Words like “should,” “have to,” “must,” and
“ought” usually signify tolerance, not acceptance, as do “suck it up” and
“put up with it.” Here are two ways we may reply to such comments:
Client: I guess I have to suck it up and move on.
Therapist: Well, that is an option, I suppose. But “sucking it
up” is not usually very satisfying. I’m wondering if
you’d be interested in learning a new strategy—
something that’s very different from sucking it up?
Client: Are you saying I should just put up with it?
Therapist: No, not at all. “Putting up with stuff” is a pretty
life-draining experience. I’m wondering if you’d be
open to trying a new approach that’s radically
different from putting up?
 If clients are open to something new and different, we can move
into teaching acceptance skills. However, before we go into that, we
need to touch upon three important topics: emotion dysregulation, the
positive functions of “negative” emotions, and exposure.

Emotion Dysregulation
From an ACT perspective, we can define “emotion dysregulation”
as the inability to respond flexibly to emotions. Basically, the more
inflexibly we respond to our emotions (i.e., the greater the extent of our
fusion, experiential avoidance, and unworkable action), the more
problems this creates, and the greater our psychological suffering.
The antidote to emotion dysregulation is emotional flexibility:
responding to emotions flexibly—with defusion, acceptance, contacting
the present moment, self-as-context, values, and committed action. (We
can think of this as “ACT-congruent emotion regulation”—although
that’s a term I’m not keen on, as it’s easily misunderstood).
Said differently, when a difficult emotion is present, we aim to:

1. Open up: make room for it and defuse from its cognitive elements
2. Do what matters: act effectively, guided by our values
3. Be present: focus on and engage in what we are doing

This is a big paradigm shift from many other models. The

conventional wisdom is that clients first need to control the intensity of
their emotions before they can control their behavior. The problem is, if
you go along with that popular assumption, it pulls you into conflict with
ACT. Why? Because ACT assumes that although emotions influence our
behavior, they do not control it.
For sure, our emotions have massive influence over our behavior in
a context of fusion and experiential avoidance—but much less so in a
context of mindfulness and values. So in ACT we don’t try to reduce the
intensity of the emotion, or distract from it, or make it go away. Instead
we work on helping the client to stay present, acknowledge and allow
their inner experience, stay in touch with their values, and exert control
over their physical actions—no matter what emotions are present or how
intense they are.
Of course, as we do this, the emotion is usually reduced; for
example, every published study on ACT for anxiety disorders shows
significant reductions in anxiety levels. However, in ACT, as mentioned
earlier, this common outcome is a bonus, not the main aim. Our primary
objective is to help people live meaningful lives through acting on their
values and engaging in what they do, while accepting their private
experiences.
Now having said all this, if we really need to, we can bring in other
skills to directly reduce or distract from painful emotions (see chapter
twenty-three). But this is rarely if ever necessary—especially if we’re
doing lots of dropping anchor.

Positive Functions of “Negative”

Emotions
There’s a classic ACT saying: “Your pain is your ally.” This is a
radically different perspective for most clients, who typically see painful
emotions as the enemy. So brief psychoeducation about the positive
benefits of “negative” emotions is essential. I put “negative” in quotes
because ACT generally steers away from this terminology. In many
models, emotions that feel unpleasant are labeled “negative,” while those
that feel pleasant are labeled “positive.” But in ACT, we’re primarily
interested in the functions of an emotion: the effects it has on behavior.
So-called “negative” emotions (e.g., anxiety, sadness, guilt) have
evolved over eons because in certain situations they offer significant
survival advantages. In other words, in some contexts, “negative”
emotions have positive functions: life-enhancing effects on behavior.
These positive functions fall into three main classes: motivation,
illumination, and communication. Our emotions motivate us to behave in
particular ways, illuminate what is important, and help us to
communicate with others.
 MOTIVATION
Anger motivates us to stand our ground, to fight.
Guilt motivates us to make amends, to repair social damage.
Shame motivates us to make amends, repair social damage, and
cease behaviors that alienate.
Sadness motivates us to slow down, withdraw, and rest.

ILLUMINATION
Anger illuminates the importance of defending our territory,
protecting a boundary, or standing up and fighting for what we care
about.
Guilt illuminates the importance of how we treat others and the
need to repair social bonds.
Shame illuminates the importance of others and the way we treat
them, and the benefits of belonging to the group.
Sadness illuminates the importance of rest and recuperation after a
loss.

COMMUNICATION
Anger communicates “This isn’t fair or right” or “You’re
trespassing on my territory” or “I’m defending what’s mine.”
Guilt communicates “I’ve done something wrong and I want to
make it right.”
Shame communicates “I have failed” or “I am defeated.”
Sadness communicates “I’ve lost something important.”

WHAT ABOUT FEAR AND ANXIETY?

Technically, anxiety is a response to a future threat (i.e., something
dangerous we are expecting to happen): the vicious dog that might be
running loose in the park. In contrast, fear is a response to a present
threat (i.e., something dangerous that is happening now): the huge
Rottweiler that is now running toward us, snarling and growling. In
clinical practice, however, the terms are largely interchangeable.
With many emotions we’ll need to formally explain the adaptive
benefits because they aren’t obvious (as with shame, for example: see
chapter twenty-four). But when it comes to fear and anxiety, almost all
clients can readily identify some positive functions, such as motivation,
and we can fill in the blanks as needed. For example:
Therapist: Have you ever wondered why we have emotions
like fear and anxiety?
Client: Not really.
Therapist: Well, has there ever been a time where these
emotions helped you?
Client: Errr. I guess. Yeah, when I was a student. I’d get
anxious about failing, so that would motivate me to
study.
Therapist: Yeah, so anxiety can motivate us to prepare and
plan ahead for future dangers, and if possible, take
action to prevent them. Any other ways anxiety or
fear has been useful?
Client: I guess it stops me from walking down dark
alleyways.
Therapist: Yes, so that’s another benefit; these emotions
motivate us to avoid or stay away from danger.
Another thing with fear and anxiety—they tend to
give us a lot of “nervous energy”—because they’re
preparing us to take flight, to run away. Has that
energy ever been useful to you? Have you ever
been able to channel it into something?
Client: Well, I guess if it’s after dark, then it helps me to
walk home as fast as I possibly can.
 Therapist: To get to the safety of home?
Client: Yeah.
Therapist: So there’s another benefit: these emotions give
us energy to run away from threats and get
ourselves to safety.
When we explore the illumination functions of any emotion, we can
readily link it to values, as below:
Therapist: Another purpose of any emotion is to illuminate
what we care about: what’s important, what
matters to us. So what does your anxiety tell you
really matters to you?
Client: Well, my kids. My health. My marriage. My safety.
Therapist: For sure. That’s really important to you, right?
Anxiety is reminding you of that. And in fact, that’s
what our work here is all about—helping you to
take care of those important aspects of life.
If needed, we can be more didactic:
Therapist: Well, your anxiety seems to cluster around several
recurrent themes. You worry about your children and
your marriage, and your health—and you’re very
concerned for your safety and for theirs. So anxiety is
really reminding you that these things are super
important; you need to take care of them.
And here’s how we may explain the communication functions of
emotions:
Therapist: The other big purpose of all emotions is that they help
us communicate with others. For example, if I ask you
now to do some exercise, and you look anxious, that
communicates to me that you find my suggestion a bit
threatening. And that’s important for me to know
because then I can do something to make it less
 threatening. So fear and anxiety communicate to
others that there is something you find threatening or
dangerous—and if those other people are caring and
kind, then knowing that will motivate them to support or
look out for you.

DO COGNITIONS CAUSE EMOTIONS?

To reiterate an important point, in ACT we do not assume that
cognitions cause emotions. Our cognitions influence our emotions—
along with many other factors: our physiological state, the external
environment, the situation we’re in, the activity we’re doing, and so on.
(And, of course, our emotions also influence our cognitions.)

Acceptance and Exposure

Almost all evidence-based treatments for trauma-related disorders have
exposure at their core. And although there are numerous definitions of
exposure, they mostly boil down to something like this: “organized
contact with fear-evoking stimuli to facilitate habituation.” Now let’s
unpack that.
“Habituation,” in layman’s terms, means becoming accustomed to
something. When we habituate to a stimulus, we get used to it, so it
becomes less distressing. “Fear-evoking stimuli” may be external (e.g.,
social situations in social anxiety disorder, or confined spaces in
claustrophobia) or internal (e.g., cognitions, emotions, sensations,
memories). The aim in models that embrace this concept of exposure is
to (a) get clients in contact with stimuli they fear, and (b) maintain that
contact until distress or anxiety significantly lowers.
The problem is, this popular concept of exposure is based on
scientific research that is now quite old, and somewhat questionable. In
contrast, inhibitory learning theory offers a contemporary account of
exposure, which differs significantly from older models (Arch & Craske,
2011; Craske et al., 2014). Inhibitory learning theory (IHL) suggests that
habituation is not the main mechanism for positive behavioral change
following exposure.
IHL proposes that when clients contact fear-evoking stimuli during
exposure, they learn new, more effective ways of responding—and these
new learnings then inhibit (but do not eliminate) older responses. The
research referenced in the previous paragraph shows there is no
correlation between the drop in distress/anxiety during exposure and the
positive behavioral changes that result.
Said differently, even when clients have no change at all in
distress/anxiety levels during exposure, significant positive behavioral
change can happen. And on the flipside, clients may have large drops in
distress/anxiety during exposure without any positive behavioral change
at all. (If you’re surprised by this, please do read the papers referenced
above; times are changing, and IHL increasingly influences many
models of therapy.)
In summary then, according to IHL, when effective behavior
change occurs through exposure, it is not because of a drop in anxiety or
distress, but from learning new, more flexible responses that inhibit the
old, ineffective ones.
Now ACT’s model of exposure is not identical to that of IHL, but
the two are extremely similar and complementary. In ACT, we define
exposure as “organized contact with repertoire-narrowing stimuli to
facilitate response flexibility.” Again, let’s unpack that.
By “repertoire-narrowing,” we mean that when we contact these
stimuli, our behavior narrows down to a small range of rigid, ineffective
responses. “Repertoire-narrowing stimuli” is a much bigger category
than “fear-evoking stimuli.” Repertoire-narrowing stimuli may evoke
fear, sadness, guilt, shame, anger, or any other emotion. Our primary
concern is not what emotions these stimuli evoke, but the narrow
behavioral repertoires they cue.
To understand ACT-style exposure, see the choice point diagram
below. Repertoire-narrowing stimuli—emotions, cognitions, situations—
are at the bottom. (“Situations” include any context where you can see,
hear, touch, taste, or smell repertoire-narrowing stimuli in the external
world, such as people, places, objects, events, and activities.) Away
moves are the narrow repertoires that result from repertoire-narrowing
stimuli.

In ACT, the aim of exposure is not to reduce distress or anxiety

(although this commonly occurs). Rather, it is to respond more flexibly
to repertoire-narrowing stimuli so you can be more effective in doing
things that create a meaningful life. “Response flexibility” includes
emotional flexibility, cognitive flexibility, and behavioral flexibility. And
on the choice point, these flexible responses are called towards moves.
(John Forsyth and Georg Eifert clearly laid out the procedures for ACT-
style exposure in their 2005 textbook, ACT for Anxiety Disorders [Eifert
& Forsyth, 2005]; TFACT builds upon that excellent foundation.)
So what has all this got to do with acceptance? Well, when we turn
with openness and curiosity toward difficult, painful, or threatening
private experiences that we usually try to avoid—and we willingly allow
them to be present without letting them control our behavior—that is
exposure! It’s organized contact with repertoire-narrowing stimuli, to
facilitate response flexibility.
Of course, there are many private experiences we find easy to
accept: pleasant emotions, happy memories, comforting thoughts, and so
on; accepting those experiences is not exposure. But when we accept
difficult, unwanted emotions and cognitions that usually trigger
problematic behavior—that is exposure.

Graded Exposure
“Graded exposure” means gradually exposing yourself to
repertoire-narrowing stimuli in a way that enables you to remain
psychologically flexible at each step. Earlier, I mentioned the gym
metaphor: you don’t go straight for the heaviest weights; you start with
light ones and build up over time. The same principle applies with
graded exposure; we encourage clients to develop their acceptance skills
over time: begin with less challenging private experiences, work up to
more difficult ones.
For example, when clients are highly avoidant of anxiety, we may
initially focus on accepting just one physical sensation—like a racing
heart or a knot in the stomach. We could then choose another one, and so
on. From there, we can move on to other components of anxiety, such as
thoughts and urges, until the client can accept all aspects of the
experience. Here’s a playful way to communicate this:
Therapist: Do you know that old joke, “How do you eat an
elephant?”
Client: (smiling) One mouthful at a time.
Therapist: Corny as it is, there’s a lot of wisdom in that joke.
Rather than trying to deal with some massive
overwhelming emotion, we want to focus on one
small bit at a time.

THE THREE COMPONENTS OF AN

EMOTION
There are three experiential components to any emotion: sensations,
urges, and cognitions. We can work with any of these elements during
exposure and acceptance.
 Sensations
For many people (but not everyone), physical sensations in the
body are the predominant experiential aspect of an emotion. For
example, with anxiety, clients may notice muscle tension, shaking,
sweating, numbness, knots in the stomach, a lump in the throat, tightness
in the chest, a racing heart, and so on.
Urges
All emotions come with urges and impulses. With anxiety, there
may be urges to worry, seek reassurance, take drugs, drink alcohol,
smoke a cigarette, distract oneself, leave a situation, and so on.
Cognitions
Cognitions are an intrinsic element of all emotions and urges. For
example, when experiencing anxiety, clients may have thoughts like I’ve
screwed it up, Something bad is going to happen, I can’t stand this, and
so on. Note that “cognitions” is a broader term than “thoughts.”
Cognitions may include the labels we give to the experience (e.g.,
anxious, nervous, jittery, shaken), the meaning we make of it (e.g., “I
feel scared so that means I’m in danger”), and the images or memories
that go with it.
As you’d expect, we use defusion to work with the cognitive
component of emotions, so since we’ve already covered that, we’ll now
focus on the other elements: sensations and urges. (You’ll notice, though,
that I often talk about “emotions, urges, or sensations” for ease of
discussion.)

Values-Guided Exposure
In ACT, the primary aim of exposure is to help people live by their
values so they can build more meaningful lives. This is a big difference
from other models, where the primary aim is to reduce anxiety or
distress, and we need to make it explicit before formal exposure begins:
Therapist: (immediately following the Pushing Away Paper
exercise) So I just want to be clear about the main
benefit of learning how to do this. It’s so that when
these difficult thoughts and feelings show up, instead of
doing away moves, like (mentions problematic
behaviors the client commonly does in response to the
emotion), you can do towards moves, things that help
you build the sort of life you want. So is it okay if we
take a moment just to clarify what those towards
moves are?
We now help the client to reconnect with their towards moves,
recapping the values or goals previously established. (And if we don’t
yet have this information, we need to gather it now, as outlined in
chapter five.) We can repeatedly use this information to facilitate
acceptance:
Therapist: So let’s just take a moment to really get in touch with
what this is all about. We’re doing this work so that you
can be more like the sort of dad you really want to be—
patient with the kids, playing with them more. And it’s
also about the husband you want to be—more loving,
more giving, more open.
In the worst-case scenario, if the client can’t identify any towards
moves at all, we have two options, both equally valid:
A. We put acceptance on hold and move into values clarification,
as described in chapter fifteen; then return to it later, once values-
based goals are established.
B. We carry on with acceptance but use vague, generic terms, such
as “self-caring” or “caring for others” as values, and “building a
better life” as a goal. We would say, “So for now, how about we
say your main motivations are ‘self-caring’ and ‘building a better
life’?”
 Actively Building Acceptance Skills
Through Exposure
Everything we’ve covered in the previous chapter and this one
paves the way for actively learning acceptance skills. So now we need to
use exposure techniques to bring an emotion or urge into the room:
Therapist: If you were learning to play guitar, we’d need to have
a guitar here for you to practice on. And it’s the same
with these new skills for handling emotions—we need
to bring the emotion into the room, so we can work with
it. I’m wondering, are you feeling it at all, right now?
If a difficult emotion, urge, or sensation is already present, then we
start working with it. But if not, we need to evoke it, as described below.
Anxiety is the main emotion that clients with trauma-related disorders
try to avoid. But it’s rarely if ever the only one; anger, shame, sadness,
guilt, and loneliness are also commonly avoided. The good news is,
acceptance skills are transferrable: we can use the same tools and
techniques with any emotion, sensation, or urge, including feelings of
numbness, emptiness, and physical pain. So we can help clients develop
acceptance skills with any unwanted feeling that arises.
For example, suppose the client really struggles with sadness, but
they can’t tap into it during the session. If so, they are likely to feel
frustration, disappointment, or anxiety—in which case, we work with
those emotions instead. Fortunately, the strategies below work well to
help most clients access difficult emotions.

RELIVE A MEMORY
We can help the client to relive a memory of a time where they
were intensely feeling this sensation or urge. (At this point in therapy, we
don’t want clients to deliberately recall traumatic memories; there are
many precautions we need to take for such work, as discussed in chapter
thirty. So we help the client pick a memory of something moderately
stressful, but not traumatic. And if we can’t safely do that, it’s better not
to use this particular method.) Useful questions to ask include:

Can you recall the last time you were feeling this urge/sensation?
Can you describe it to me as if it’s happening right now? Where are
you? What can you see and hear? Who are you with? What’s going
on? What are you feeling?

Once the client contacts their emotion in the memory, we can ask:

And as you’re sitting here with me, right now, is that feeling
starting to show up? Can you feel it in your body at all?

IMAGINE A FUTURE SCENARIO

We can help the client vividly imagine a forthcoming difficult
situation, and ask the same questions as above:

Can you describe it to me as if it’s happening right now? Where are

you? What can you see and hear? Who are you with? What’s going
on? What are you feeling?

And again, once the client contacts the emotion in the imaginary
scenario, we can ask:

And as you’re sitting here with me, right now, is that feeling
showing up at all?

DO AVOIDED TASKS
If clients are avoiding difficult tasks, such as making a phone call,
sending an email, starting a study assignment, making an appointment,
writing a resume, researching a job, joining a group, putting in an
application, and so on, we can encourage them to do these things during
the session.
 LET YOUR GUARD DOWN
Some clients “keep their guard up” in session (i.e., do things that
give them a sense of safety and protection, such as covering their legs
with a coat, adopting an arms-folded posture, or keeping their cell phone
switched on and by their side). We could encourage them to experiment
with changing that: put aside the coat, unfold their arms and adopt a
more open posture, or put the phone away.

SET CHALLENGING GOALS

Almost always, when we start actively setting goals in session that
are going to pull the client out of their comfort zone, difficult sensations
and urges will show up: feelings of anxiety or urges to change the topic,
end the session, or stop the exercise.

URGE-EVOKING EXERCISES
In session, we may be able to organize contact with stimuli that
usually trigger urges for the client. For example, if smoking or binge
eating is the issue, you might ask the client to bring in a pack of
cigarettes or a sample of the food they binge on, and ask the client to
look, touch, taste, or smell these items and notice the urges that arise.
For the urge surfing exercise described later in this chapter, I like to
work with urges to swallow. The client places a grape, or a piece of
chewy candy such as Mentos, on top of their tongue and lets it sit there,
without chewing or swallowing. Saliva rapidly builds up—and with it,
the urge to swallow. We then coach the client to acknowledge and allow
the urges to swallow or chew, without acting on them. (See Extra Bits for
a script.)

FEAR-EVOKING EXERCISES
To evoke fear and anxiety, there are many well-established
techniques we can draw upon that are used in many other models, such
as asking clients to hyperventilate. We cover these in chapter twenty:
“Compassionate, Flexible Exposure.”

ANTICIPATORY ANXIETY
Often, just anticipating the forthcoming exercise is enough to
trigger anxiety—in which case, we can work with that:
Therapist: I’m wondering, now that you’re about to take the
plunge and practice this new skill, what kind of
feelings are showing up?
Client: I’m a bit nervous.
Therapist: Okay. So how about we work with your
nervousness? Where are you feeling this in your
body?
In addition, the urge to avoid the exercise almost always arises:
Therapist: Are you noticing any urge to try to get out of the
exercise?
Client: Err, yeah.
Therapist: How about we work with that urge? Where are
you feeling this in your body? Are you tensing up
anywhere? Noticing any impulses in your arms,
legs, hands, feet?

Safety and Defusion Before Intense

Experiential Work
As we do this work, all the safety factors discussed earlier come
into play. This includes checking that the client is genuinely willing (not
coerced); continually tracking their responses, to ensure they’re within
their window of flexibility (i.e., able to focus, engage, and control their
physical actions); and dropping anchor as needed, to keep them within
that window. It’s also wise to preempt fusion: “As we do this, your mind
is probably going to say some unhelpful things, so see if you can let it
chatter away in the background, like music playing in a supermarket.”
If fusion does arise during the exercise (e.g., “This is silly,” “I can’t
do it”), we notice and name (“So notice what your mind is doing here”)
or normalize and acknowledge the purpose. (“It’s natural to have
thoughts like that. It’s a challenging exercise, and your mind wants to
save you from the discomfort.”) Alternatively, we can link to values:
“Let’s take a moment to connect with why you’re doing this in the first
place… (Therapist recaps the client’s values and goals.) So can we keep
going, even though your mind says ‘It’s bullshit’?” And if all that is still
not enough, we can bring in the “big three” from chapter eleven: write,
move, expand awareness.

NAME the Emotion

Once a difficult emotion or urge is present, we can start cultivating
acceptance. (And there’s a huge range of exercises we can draw upon;
the few we cover here are the tip of the iceberg.) One popular practice is
to NAME the emotion or urge (Harris, 2009b). The acronym, NAME,
stands for:
N—Notice the sensations
A—Acknowledge by name
M—Make room
E—Expand awareness
Using these components, we go through an exercise with our client
to help them develop acceptance.

NOTICE THE SENSATIONS

The NAME process begins with noticing the physical sensations of
an emotion or urge:
 Therapist: So where are you noticing this in your body?
Client: My chest.
Therapist: What’s it like in there?
Client: It’s tight. Feels kind of hard to breathe.
Therapist: Anything else you notice in there?
Client: My heart!
Therapist: What’s it doing?
Client: Pounding away.
Therapist: Okay—so tight chest, pounding heart. Anywhere
else you’re feeling this?
Client: Errr—my throat.
Therapist: Yeah? What’s the feeling in there?
Client: It’s kind of—like a lump there. Like I can’t swallow.
We continue this for a minute or so, identifying what the sensations
are like and where they are in the body. Often, we ask leading questions:
“Are you feeling anything in your face? Noticing anything in your jaws?
How about in your throat? Neck? Shoulders? Chest? Abdomen?”
If we’re working with an urge, we’d ask, “Are you noticing the urge
or impulse to do something? Is there anywhere in your body you
particularly feel that? Is any part of your body tensing up, getting fidgety
or jittery? Are you noticing any tension in your arms, legs, back,
shoulders, neck?”

ACKNOWLEDGE BY NAME
Therapist: So what would you call this emotion?
Client: It’s anxiety!!!
Therapist: Okay. Could you just take a moment to
acknowledge this feeling by name? Say “I’m
noticing anxiety.”
Client: I’m noticing anxiety.
Therapist: Does it make any difference when you say that?
Client: Not really.
Therapist: Okay, so can we try that again, but this time, a bit
differently—and as well as saying the words, see if
you can really notice what you’re feeling. The idea
is to help you sort of step back and watch the
anxiety, instead of being in the thick of it. Have you
ever been outside when it suddenly starts pouring
rain—and then you take shelter in a doorway or
something—and you can watch it pouring down
without getting drenched by it?
Client: Yeah.
Therapist: So noticing and naming what you’re feeling
usually helps you do the same thing; it doesn’t
stop the anxiety, just helps you step back a little,
so you can watch it.
Client: Okay.
Therapist: Cool. So this time, say, “I’m having a feeling of
anxiety, and I’m noticing it in my chest, throat, and
tummy.”
Client: “I’m having a feeling of anxiety, and I’m noticing it in
my chest and throat and tummy.”
Therapist: Any difference that time? Any sense of stepping
back, watching it?
Client: Yeah, it did kind of help me to do that, a little.
 Noticing sensations and acknowledging them by name can
sometimes have dramatic effects—and occasionally, no effect at all.
Most clients will be somewhere in between these extremes. If there’s
little or no obvious benefit, we take that in stride: “Okay,” “Cool,” “No
worries,” or some similar response, delivered with warmth and openness.
If a client is finding it hard to name an emotion, we can make
suggestions: “Is it sadness, maybe?” And if they are using more
colloquial language (e.g., “nerves,” “jittery,” “shaky”), we might say,
“Sounds like that might be anxiety?” Naming urges is much simpler:
“I’m noticing the urge to shout,” “Here is the urge to smoke,” and so on.

Practical Tip
There’s rarely only one painful emotion showing up, so it’s often
helpful to ask about others (e.g., “Is it all anxiety—or are there
other feelings too? Any sadness or anger or shame?”)

We can also usefully speak metaphorically about “layers” of

emotion: “Often underneath our anger, there’s another emotion
—like fear or guilt or sadness. See if you can peel off the top
layer; is there maybe something else underneath?” If other
emotions are present, we work with whichever the client finds
most difficult.

MAKE ROOM FOR IT

We have a huge range of techniques for helping clients to open up
and make room for these difficult sensations, and usually we combine
several. Popular methods include:

Noting Properties: noticing and describing the physical properties

of a feeling—size, shape, temperature, movement, borders, and so
on
Physicalizing: imagining the feeling as if it’s a physical object
 Breathing into it: imagining, sensing, or visualizing your breath
flowing into and around the feeling
Expansion: using the metaphor of expanding around the feeling

Throughout this process we encourage the client to observe the

feeling with genuine openness and curiosity. For example:
Therapist: So out of all those different areas, where is it
bothering you most?
Client: In my gut.
Therapist: Okay. So see if you can observe this feeling as if
you’re a curious scientist who’s never seen
anything quite like this.
Client: Okay.
Therapist: And you’re focusing in on just this one feeling, in
your tummy…
Client: Right.
Therapist: And just like a scientist, you’re aiming to discover
something new here—maybe something you’ve
never noticed before.
Client: I normally try not to notice it!
Therapist: That’s right. This is the very opposite of what you
usually do. Are we okay to keep going?
Client: Okay.
Therapist: (noting properties) So can you give me a sense
of the shape and size of this feeling? Like, with
your finger, could you trace the outline for me?
Client: (tracing a circular shape, mid-abdomen) It’s mostly
here.
Therapist: And flat like a pancake, or more like a 3D object?
Client: It’s like a ball.
Therapist: A ball? Right. And where is it sitting? Like is it at
the surface or deep inside or…
Client: Err, it’s quite deep—sort of right in the middle.
Therapist: And what’s the temperature in there? Are there
any hot spots or cold spots?
Client: Errmm—it’s, it’s—I never thought about it before—
It’s kind of hot.
In addition to the above questions, we could ask:

Is it moving or still?
Light or heavy?
Are the edges well defined or vague and blurry?
Can you notice any vibration or pulsation or movement within it?
Is there any pressure in there?
Any burning, tingling, throbbing, cutting?

After this, we may move into “physicalizing” (Hayes et al., 1999):

Therapist: (physicalizing) Now, I’m wondering if you could
imagine this feeling as if it’s a physical object
inside you.
Client: Okay.
Therapist: So is it liquid, solid, or gaseous?
Client: Solid.
Therapist: And light, heavy, or weightless?
Client: Oh, heavy.
 Therapist: And if it had a color, what would that be?
Client: Black.
Therapist: So it’s like a hot, heavy, solid, black ball—in the
middle of your tummy.
In addition to the above questions, we could ask:

Is it transparent or opaque?
All one color, or several?
If you could reach in and touch the surface, what would it be like:
rough, smooth, wet, dry?

Keep in mind, a small number of people find visualization

extremely difficult (I’m one of them); so if clients struggle with these
visual elements—skip ’em! And note: there’s no attempt to change the
feeling (e.g., make the ball smaller or dissolve it). Often that kind of
change spontaneously happens, but it’s not something we’re aiming for;
the purpose of the exercise is to accept the feeling as it is. So if it does
reduce in size and intensity: nice bonus, not the main aim.
The next step is to breathe into the feeling, which most people find
quite soothing. (But if it triggers unpleasant reactions, skip it.)
Therapist: (breathing into it) Now see if you can gently
breathe into this—no big dramatic breaths—just
gently, breathing in, and imagining your breath
flowing into and around this feeling… (Therapist
pauses for a few seconds, as client does this.)…
that’s it, slowly and gently… (pause)…breathing
into it… (pause)…breathing around it… (pause)…
not trying to get rid of it, just letting it be there, and
breathing into it… (pause)…are we okay to keep
going?
Client: Yeah, we can.
Therapist: (expanding around it) Great…so as you’re
breathing into it, keep observing this feeling…look
at it from all angles…from the front and the back,
the top and the bottom…and see if you can kind of
open up around it…kind of like you’re expanding
around it, making lots of space for it…and just
taking a moment to connect with why you’re doing
this—so you can be more playful with the kids,
more loving with your wife, more like the dad and
husband you want to be…and in the service of
those values, opening up and making room for this
feeling…and are we still okay to keep going here?
Client: Yeah, yeah.
Therapist: So I’m wondering, is it getting any easier to let
this feeling be there? To just kind of have it there,
without fighting it?
Client: Well, I don’t really like it…
Therapist: Of course not. Who would? I’m not expecting you
to like it at all, I’m just wondering if you’re getting
that sense of just letting it be, without struggling?
Client: Yeah, yeah. I’m getting that.
Therapist: So on a scale of zero to ten, where ten means no
struggle at all, “I’m absolutely willing to make room
for this feeling (extends her arms outward and
sideways in a posture of openness, to accentuate
the point) and let it be here, even though it’s
awful”; and zero means “I absolutely have to get
rid of this feeling right now (crosses her arms
tightly across her chest, in a posture of closing off),
I can’t bear it a moment longer, I need it gone”;
and five is the halfway point we call tolerating it or
putting up with it…where are you now on that
scale?
 Client: Ten is no struggle?
Therapist: Right—you’re absolutely willing to have it,
without fighting it, no matter how bad it is.
Client: I’m probably a seven.
Therapist: That’s great. Can we keep going with this, a bit
longer?
Client: Okay.
Therapist: Great. So, keep observing this feeling. And
notice…this feeling is not you; it’s something
passing through you, just like clouds pass through
the sky.
Note how the therapist introduced a willingness scale, where ten =
complete willingness (i.e., zero avoidance, complete acceptance), and
zero = no willingness (i.e., zero acceptance, maximal avoidance). This is
a useful subjective measure of experiential acceptance. In some sessions,
clients may reach a ten, but often they don’t—and that’s not a problem.
(I’m sure you can relate to this; at times, we’re pretty good at accepting
painful feelings; at other times, we suck at it.) Over time, with practice,
we expect clients to improve their acceptance skills; if they can reach a
seven, that’s a good start.

Kind Hands
Often at this point, we bring in the Kind Hands exercise to foster self-
compassion:
Therapist: I invite you to take one of your hands and turn it
palm upward (client does so) and see if you can fill
that hand with a sense of real kindness…you’ve
used this hand in a lot of kind ways in your life,
right? Did you cuddle your babies, when they were
upset?
 Client: For sure.
Therapist: Hold your kids’ hands when they were scared?
Client: Uh-huh.
Therapist: Used it to help other people lift things, move
things, do things?
Client: Yep.
Therapist: So see if you can get a sense of that kindness
and support that you’ve given to others, and in
some way, put it into this hand right now—as if
your hand is filling up with kindness.
Client: Okay.
Therapist: Now I’m going to give you a choice here—either
rest this hand gently on top of your tummy, or, if
you prefer not to actually touch, just hover it
slightly over the surface. (The therapist takes their
own hand and rests it on their own tummy, to
demonstrate. The client follows suit.) Great. And
see if you can send that kindness inward—you
might feel it, or imagine it, or sense it—a sense of
warmth and kindness and support, flowing into
you.
Some clients, for reasons discussed in chapter eight, do not
want to touch their body, so always give them the option of letting
their hand hover, rather than directly touching. Another option is to
cup their hands together, rest them in their lap, and then imagine,
feel, or sense the kindness “filling up the cup”; and from there,
flowing up the arms, into the body, and into the pain (or numbness).
Therapist: And see if you can send that warmth and
kindness into and around this feeling…breathing
into it…expanding around it…see if you can soften
up around it, hold it gently…hold it like it’s a crying
 baby, that needs comforting…and what’s
happening?
Client: (eyes slightly teary, voice softer) It’s err—yeah—I’m,
err—it’s good (breathes a sigh of relief).
Therapist: Okay to keep going?
Client: Yeah.
Therapist: Ten is complete willingness to have this feeling,
zero is totally unwilling, five is tolerating it. What
are you at now?
Client: I’m at a nine.

EXPAND AWARENESS
We end with E: Expand awareness (similar to Engage, in dropping
anchor). Returning to our Kind Hands exercise…

Kind Hands: Conclusion

Therapist: So in finishing up, notice there’s anxiety here…and
also notice that sense of opening up, making room for
it, letting it be…and notice that around this feeling you
have a body…and perhaps, having a stretch?…
(therapist stretches, client copies)…and also noticing
the room around you…what you can see and hear…
and breathing in the air, noticing what that’s like…and
noticing you and me here, working together, (playfully)
doing these weird exercises (client smiles)… So how
was that?
What Do I Do Next?
As a part of debriefing the exercise, we say: “So, the question is,
after you’ve done this, what next? Well, if what you’re doing is
important, meaningful, life enhancing—then you keep doing it, and give
it your full attention; really focus on it, and get absorbed in it. But if it’s
not really important or taking you toward the life you want, then the idea
is to stop, and do something else that is.”
Usually, by this point in therapy, we’ve already explored questions
like “If this urge/emotion wasn’t controlling you, what would you do
differently?” But if not, now is a good time to do so. Of course, some
clients have no idea what to do differently, in which case we can make
suggestions, such as scheduling pleasant activities (chapter sixteen) or
doing self-soothing practices (chapter twenty-three).
When Clients Can’t Label Their Emotions
Some people have little or no ability to name their emotions.
Technically this is known as “alexithymia”—which, in Greek, means
“no words for feelings.” In such cases, we work on emotional literacy:
teaching clients to distinguish and label different emotions, much as we
would a young child. When we see evidence that the client is feeling
something (e.g., they look or sound angry, sad, anxious, guilty), we ask
them to tune into their body, notice where they are feeling it, what it’s
like, and what they feel like doing. We can then help them label the
emotion: “You feel like crying and curling up into a ball? Tears in your
eyes? Heavy chest? That is sadness”; “You feel like yelling, hitting,
smashing things? Fists clenched? Jaws tight? Heart pounding? That’s
anger.” And so on. We may start with the “big four”—sad, mad, glad,
scared (sadness, anger, joy, fear)—and then gradually expand the
repertoire. (With a quick google search, you’ll find many free “emotion
charts,” useful for this work.)
Duration of Exercises
Most acceptance exercises last from two to twenty minutes. The
duration varies hugely, though, depending on the client’s issues, their
level of experiential avoidance, and the ACT skills they already have.
For example, with a client extremely high in experiential avoidance,
phobic of their own emotions, we might start with a sixty-second
exercise. Next time, we may increase it to ninety seconds, and after that,
to two minutes, and so on.
 Practical Tip
The longer the duration, the more important it is to regularly
connect with values throughout the exercise. We might say, for
example, “And just take a moment to connect with why we’re
doing this” or “And remind me, what’s this in the service of?”

Surfing Urges and Emotions

The term “urge surfing” was originally coined by psychologists
Alan Marlatt and Judith Gordon as part of their mindfulness-based
approach to working with drug addiction (Marlatt & Gordon, 1985). It’s
an acceptance technique utilizing the metaphor that urges are like waves:
they rise, peak, and then fall. (The same metaphor also applies to
emotions.) And the idea is to “surf” the wave, rather than resist it. This
means you observe the inner experience mindfully—and allow it to rise
and peak and fall again, without acting on it. We can bring in surfing
exercises either as an addition to or as an alternative to NAME exercises.

INTRODUCING THE WAVE METAPHOR

Therapist: You know how a wave in the ocean starts off
small, then it gathers speed, and it grows bigger
and bigger, until it reaches a peak—and then it
gradually subsides?
Client: Yeah?
Therapist: Well, the same thing happens with emotions and
urges. They’re like waves. As long as we don’t
resist them, they rise, they peak, and they fall—
usually quite quickly. But if you resist a wave, what
happens?
Client: You get slammed.
 Therapist: Yep, the wave smashes you around. So the aim
in this exercise is to make room for those waves—
to surf them, instead of resisting them.

BUT MY WAVES LAST FOREVER!

Sometimes clients will protest that their waves go on and on and on
for ages. We would compassionately validate, “Yes, that’s right. At the
moment, they do. And there’s a good reason for it. It’s because you’re
doing the same thing that we all naturally, instinctively do: you’re
resisting them.”
Following that, we would recap what the client usually does in
response to urges/emotions. We might say, “And what I mean by that is
you tend to…here, we recap a few of the client’s main inflexible
responses: fight with them, ruminate about them, worry about them, try
to distract yourself, try to push them away)…and whenever we respond
to them that way, it makes them go on for ages. No one ever taught you
how to surf them, so you’ve never experienced what I’m talking about;
but what you’ll find when you try it is that the waves usually rise and fall
pretty quickly.”

HOW TO SURF
Urge surfing and emotion surfing exercises utilize the basic steps of
NAME. To surf an urge or emotion—rather than be “slammed,”
“dunked,” or “wiped out” by it—you first Notice the sensations and
Acknowledge the experience by name. Then, in the Make room phase,
you use the metaphor of a wave: observing the experience as it rises,
peaks, and falls. We can ask clients to rate the wave, on a scale of zero to
ten: ten is the strongest this urge or emotion has ever been (the highest
peak ever), and zero means it has completely disappeared.
Therapist: How strong is it now?
Client: It’s about a seven.
Therapist: Can we keep going?
Client: Okay.
Therapist: Remember, no matter how big that wave gets, it
can’t get bigger than you. And if you give it enough
space, then sooner or later it will peak, and then
subside. So breathe into it, open up around it,
make lots of space…
Client: I hate it.
Therapist: So notice your mind, trying to hook you… Can
you let your mind have its say, and carry on?
Client: Okay.
Therapist: And what’s the wave up to now?
Client: It’s a nine, I think.
Therapist: Okay. So keep observing. Notice where you’re
feeling it. Let it be there.
Client: Okay.
Therapist: And remind me—what values is this in the
service of?
Client: Caring.
Therapist: For who?
Client: For myself, my family.
Therapist: Cool. So let’s go back to that willingness scale
again—zero to ten, in the service of caring for
yourself and your family, how willing are you to
make room for this wave?
Client: About an eight.
Therapist: Great. So keep observing the wave. And
notice…the wave is not you; it’s something
 passing through you. Zero to ten, what’s the wave
at now?
Client: It’s going down. I think it’s about seven.
Therapist: Interesting.
Waves usually rise and fall within three to ten minutes—urges
typically faster than emotions. The exercise finishes with the E of
NAME: Expand awareness. (This is the same as in the Kind Hands
exercise, so I won’t repeat it here.)
When discussing the exercise afterward, we clarify:

While the waves typically rise and fall quite quickly, they often
don’t go all the way to zero.
This isn’t a way to control waves or make them go away; we are
simply making room for them, allowing them to rise and fall in
their own good time. In challenging situations, the waves will
continue to rise and fall—and then rise and fall again—and so on.
If we make room for the wave to flow through us, we won’t get
slammed or swept away by it, and it often falls more quickly than
we expect. This frees us up to do important, meaningful, life-
enhancing things.

Debriefing and Homework

When debriefing any exercise, we ask how the client found it, what
they got out of it, and how it could be helpful outside of session. We also
link it back to values: “This is very different from what you’ve been
doing, and being a new skill, it’s naturally tricky and challenging. So
take a moment to acknowledge that you’re doing this in the service of
something important…”
For homework, we encourage regular practice, supported by audio
recordings and handouts (see Extra Bits). Naturally, we want to
encourage as much practice as possible—while at the same time tailoring
this for each unique client, given they vary enormously in how much
they’re willing to do. This is a good time to revisit the weight-lifting
metaphor:
Therapist: You know all those little moments throughout the day
when you’re a bit anxious or sad or irritable—not
having a full-blown emotional storm, but just a bit
worked up, mildly stressed—well, think of those as “the
“light weights.” Practice on those to build up your
“psychological muscles,” and then work up to the
“heavy weights,” those really intense emotions. The
ideal plan would be to practice at least one long
exercise—using the audio recording, if you like—at
least once a day daily, but also fit in as many short
versions as you can, at times when you’re a bit
stressed or wound up.

Catching Experiential Avoidance “In

the Act”
Experiential avoidance typically shows up in many different ways
throughout a session, especially “gating” and “skating.” By “gating,” I
mean behaviors intended to lock up or hold back emotions. Clients may
do this through biting their lips, clenching their teeth, sighing, looking
away, going silent, shifting their position in the chair, changing their
body posture (e.g., folding arms, covering eyes), leaving the room,
reaching for tissues, shrugging, fidgeting, digging their nails into their
palms, laughing in a forced or inappropriate way, and so on.
By “skating,” I mean skating over the surface of particular topics
and issues, to avoid the painful emotions that go with them: Nothing
much happened, can’t recall, it was okay, that’s old news, don’t go there,
all good, went well, nothing to report, no worries, next, moving on, oh
you know what it’s like, why dwell on it, it’s over and done, who cares
anyway, doesn’t matter, same old shit, I’m over it. This may include
racing through a narrative, omitting important details, or rapidly
changing the topic.
Obviously we don’t tackle every bit of experiential avoidance; that
would definitely alienate our clients. But it’s often useful to shine a
mindful spotlight on these behaviors and turn them into opportunities to
practice acceptance. For example, in the transcript below, one of Ravi’s
therapy goals is to improve communication, connection, and intimacy
with his partner. However, whenever the therapist asks about his
feelings, Ravi pauses, strokes his chin, frowns, and then after a few
seconds says, “That’s an interesting question,” or “I’ve never thought
about it.”
Therapist: I notice that when I ask you about your feelings,
you reply, “Interesting question” or “I’ve never
thought about it.” And I’m not sure if you’re saying
that because you don’t want to talk about it, or
because you find it difficult to know what your
feelings are.
Client: Yeah, that’s an interesting question.
Therapist: Ah, see, there it is again. Now I’m willing to be
wrong about this, but my guess is, when you reply
that way, it kind of helps you skate over some
unpleasant feelings that you’d rather not contact.
(The therapist resists the urge to ask, “What do
you think about that?” knowing it would only invite
the client to get caught up in his thoughts.) The
thing is, you really want to improve things with
your partner, and one of the skills you need for that
is the ability to tune into your feelings: to notice
what they are and name them. Would you be
willing to do this right now? Can I take you through
an exercise to help you? (The therapist now takes
Ravi through a quick body scan and helps him to
notice and name his feelings.)
 Going Further with Acceptance
The exercises above focus mainly on the first three As of
acceptance (acknowledge, allow, accommodate). Let’s look at ways to
go further: the fourth A (appreciate), self-as-context, and flexible
thinking.

APPRECIATE
Once clients are sitting with an emotion, making room for it, we
may then segue into appreciation: “Our emotions are basically
messengers, loaded with important information. So now that you’ve
made some room for it, let’s see if you can extract the wisdom from this
emotion—tune into it, and see what it’s offering.”
We may then ask questions like:

What is this emotion telling you to address or face up to?

What is this emotion telling you to do differently?
What is this emotion telling you really matters to you?
(If we’ve done work on values) What values does this link to?
(If we’ve worked on self-compassion) Can you use this feeling as a
reminder to be kind to yourself?
(If working on compassion, empathy, or connection with others)
How can this emotion help you to understand others? Who in your
life may be feeling something similar? What might help them at
those times?

Questions like this quickly tap into values, needs, desires, or

important issues that need to be addressed; so if there’s still time in
session, we can start translating this into values and committed action, as
in chapters fifteen and sixteen.
Of course, a client might occasionally interpret an emotion in a way
that is unhelpful. For example, when we step out of our comfort zone,
emotions such as fear and anxiety are inevitable, but a client might
interpret them as “telling me not to do it.” If this happens, we can return
to workability:
Therapist: So your sense is that these feelings are “telling
you not to do it?”
Client: Yeah, I think so.
Therapist: Well, that’s possible—but…if you follow that
advice, where does it take you? Toward or away
from the life you want?
Client: Err, away. (confused) So, are you saying I should
ignore it?
Therapist: No. Not at all. I’m just wondering if there’s
another way to interpret this feeling, that might
help you keep moving forward.
Client: Errrmm—this is risky?
Therapist: Yeah. “This is risky. It’s new territory. Be
cautious. Take care of yourself.”
Client: Right, yeah. It does feel risky.
Therapist: Of course it does. You don’t know what’s going to
happen. Anxiety tells you to be careful; prepare;
look after yourself.

SELF-AS-CONTEXT
Throughout therapy, we repeat numerous variations of the above
exercises, and as we do so, we can plant seeds for self-as-context (the
noticing self). For example, it’s often useful to end acceptance exercises
with the ancient Sky and the Weather metaphor—which is thousands of
years old, found in Hinduism, Buddhism, and Taoism.

The Sky and the Weather

 Therapist: Your thoughts and feelings are like the weather,
always changing from moment to moment; sometimes
pleasant and enjoyable; sometimes extremely
unpleasant. But there’s a part of you that can step back
and notice those thoughts and feelings—just like
you’ve been doing in this exercise. And that part of you
is a lot like the sky. The sky always has room for the
weather—no matter how bad it gets. The mightiest
thunderstorm, the most turbulent hurricane, the most
severe winter blizzard—these things cannot hurt the
sky; and sooner or later the weather always changes.
And sometimes we can’t see the sky—it’s obscured by
clouds. But it’s still there. And even when they are
thick, dark thunderclouds, if we rise high enough above
them, sooner or later we’ll reach clear sky. So more
and more, when the emotional weather is bad, you can
learn to take the perspective of the sky: to safely
observe your thoughts and feelings; to open up and
make room for them.
In later sessions, we can repeatedly refer back to this: “You are not
your emotions. See if you can open up and make room for this, like the
sky makes room for the weather.”
Similarly, when clients are surfing emotions or urges, we may say
things like “A wave is not the ocean. Waves rise out of the ocean and go
back into it. In the same way, you are not your emotions or urges—these
things continually rise, and peak, and fall away.”

THINKING FLEXIBLY ABOUT

EMOTIONS
When an unwanted emotion is present, our mind often reacts to it in
a harsh, judgmental way (e.g., It’s bad, horrible, awful, unbearable,
getting in the way of my life; I have to get rid of it; it means something is
wrong with me). So as well as encouraging defusion from those
judgments, we encourage new ways of thinking about them, to facilitate
acceptance. For example, we may encourage clients to say to
themselves:

This emotion is normal; it’s a normal reaction to a difficult

situation.
Emotions are like the weather, and I am like the sky.
Emotions are like waves: they rise, and peak, and fall. This emotion
is intense now, but soon it will pass.
I have room for this feeling; no matter how big it gets, it can’t get
bigger than me.
I’m willing to make room for this feeling, even though I don’t like
it.
It can’t harm me; I don’t need to fight it or run from it.
I don’t have to let this control me; I can have this feeling and
choose to act on my values.
Like all feelings, this one will come and stay and go in its own good
time. I don’t need to fight it.
Drop anchor, weather the storm.
Make room for it.
This is an opportunity to practice my new skills.

(You may notice the similarity between these responses and the
popular CBT strategy “cognitive reappraisal”; the big difference is that
cognitive reappraisal usually aims to reduce the emotion, whereas these
cognitive reframes aim to accept it.)

EXTRA BIT Chapter thirteen of Trauma-Focused ACT: The

Extra Bits includes (a) a handout on practicing acceptance skills,
(b) a script for urge surfing with a grape or Mentos, and (c) a link
to an e-book on working with anger.
Takeaway
There are so many takeaways in this chapter. Here are the main ones:

The four As of acceptance are acknowledge, allow, accommodate,

appreciate.
From an ACT perspective, emotion dysregulation means inflexible
responding to emotions: fusion, avoidance, and unworkable action.
The antidote is learning to respond flexibly.
Identifying the positive functions of “negative” emotions—how
they motivate, illuminate, and communicate—fosters acceptance.
Exposure in ACT is defined as “organized contact with repertoire-
narrowing stimuli, to facilitate response flexibility.” When we
practice acceptance of unwanted private experiences that trigger
problematic behavior, that is exposure.
Acceptance is always in the service of values and values-based
goals.
 CHAPTER FOURTEEN.

Self-Compassion

There are numerous definitions of self-compassion. My own is very

simple—just six words: “Acknowledge your pain, respond with
kindness.” In other words, self-compassion involves consciously
acknowledging your pain, hurt, and suffering, and in response, treating
yourself with kindness, caring, and support.
Self-compassion has always been an intrinsic part of ACT, but in
the 80s and 90s it very much hovered in the background. John Forsyth
and Georg Eifert brought it to center stage in the early 2000s (Eifert &
Forsyth, 2005), and since then, it’s stayed firmly in the spotlight. Self-
compassion is important for everyone—especially when working with
trauma. Many of our clients have not only experienced horrific events in
the past but continue to face ongoing difficulties. They may be
struggling with physical, emotional, psychological, or spiritual pain,
often of the most extreme nature. So we aim to help them respond to
their suffering with genuine kindness and caring. Unfortunately, this is
easier said than done.

Words Matter!
For most people (practitioners included), self-compassion doesn’t come
naturally; we usually only learn it when we go down the path of therapy,
self-help, or spiritual development. Far more commonly, we respond to
our pain by:
 fighting with it
trying to escape or avoid it
fusing with it
denying, trivializing, or dismissing it
blaming, judging, and criticizing ourselves
tolerating or “putting up” with it
worrying, ruminating, or obsessing about it

Self-compassion is radically different from all of the above—so it’s

hardly surprising we encounter many misconceptions about it. Many
people find it incredibly difficult; for those with entrenched self-hatred,
it can trigger much anxiety. So it pays to go slowly, to introduce self-
compassion gently and flexibly, one small step at a time. We can
instigate it formally—that is, explain the concept, then do an exercise—
or informally, which means we bring it fluidly into our experiential work
without announcing “This is self-compassion.” You saw an example of
the informal approach in the last chapter, where the therapist introduced
the Kind Hand exercise.
With the formal approach, the language we use is important because
some clients react negatively to the term “self-compassion”; they equate
it with being weak, selfish, or self-pitying or as something religious. So a
simple way to introduce it—without using the word “self-compassion”—
is with the Two Friends metaphor.

The Two Friends Metaphor

Therapist: Suppose you’re traveling with a friend. And it’s
really tough. It’s a dangerous journey and all sorts
of terrible things keep happening. It’s knocking you
around, and you’re really struggling to keep going.
Now as you carry on with the journey, what kind of
friend do you want by your side? A friend who
says, “Ah, shut up! Stop your whining. I don’t want
 to hear about it. Stop being such a wimp. Suck it
up and get on with it!” or a friend who says, “This
is really shit. But hey, we’re in this together. I’ve
got your back, and I’m with you every step of the
way”?
Client: Yeah, I’d go for the second one.
Therapist: Yeah, me too. So what kind of friend are you
being to yourself? More like the first or the
second?
Client: The first.
Therapist: Yup, we all do it. We beat ourselves up, come
down hard on ourselves. Most of us are pretty bad
at being like the second friend. Would you be
interested in learning how to do that?
Other useful metaphors to draw out the qualities of self-compassion
include the friendly teacher or coach, who is warm, supportive, and
encouraging (as opposed to harsh, critical, uncaring), or the loving
parent who comforts and soothes the distressed child (as opposed to
ignoring, criticizing, or yelling at them).

Self-Compassion and Secure Attachment

John Bowlby was a British psychiatrist who is best known as the
originator of attachment theory (Bowlby, 1969). With trauma-related
interpersonal issues, it’s often useful to explain a bit about this theory
because it makes sense of self-defeating behavior in relationships (see
chapter twenty-eight).

Attachment Theory in a Nutshell

 A newborn infant is totally helpless, entirely dependent on its
caregivers for protection and nurture (without which, it dies). So thanks
to millions of years of evolution, infants are born with strong instincts to
seek out and stay close to caregivers who will protect and nurture them.
To use Bowlby’s terminology, infants make “bids” to their caregivers for
closeness, companionship, comfort, protection, caretaking, reassurance,
and sustenance. At birth, the basic bids are crying, whimpering, or
screaming—but as a child grows, they develop many other ways of
seeking protection and nurture.
If a caregiver responds positively to these bids—that is, if they
reliably give the child nurture, comfort, and sustenance (and do so far
more often than ignoring a bid or responding with hostility)—the child
develops a “secure attachment style” within that relationship. In other
words, the child learns that their caregiver (or “attachment figure”) is
safe, reliable, and responsive in meeting their needs, and therefore feels
secure in that relationship. Not surprisingly, there is a strong correlation
between secure attachment styles in childhood and the ability to form
secure intimate relationships later in life.
Insecure attachment styles (of which there are several types)
develop when a caregiver is not reliable and responsive, when they
ignore the child’s bids or respond with hostility. This correlates with
difficulties forming secure intimate relationships in later life—an almost
universal problem following chronic childhood abuse or neglect.

Spot the Similarities

It’s easy to see the similarities between self-compassion and secure
attachment. When we are in pain, hurting, and suffering, we need
comfort, reassurance, and nurture. Our painful thoughts and feelings are
“cries of distress”—and, when we show self-compassion, we respond to
these with kindness, caring, and support. And the more reliably and
sensitively we do so, the greater the benefit. Over time, with the regular
practice of self-compassion, we develop a “secure attachment style” with
ourselves: a sense of trust in our own ability to support, nurture, and look
after ourselves.
 A similar process goes on in therapy: the client seeks solace,
support, and security, and the therapist reliably responds with kindness
and caring. (Indeed, for some clients, this may be the first such
relationship they’ve ever had.)
Through values and committed action, we help clients build healthy
loving relationships with others who will be there for them in kind and
supportive ways. At the same time, we help them develop useful skills
for actively supporting themselves, especially when lonely or isolated;
self-compassion is foremost among them.

Building Blocks of Self-Compassion

Kristin Neff, the world’s top researcher on self-compassion, describes
self-compassion in terms of three processes: (a) mindfulness, (b)
kindness, and (c) common humanity (Neff, 2003).
Mindfulness and kindness need no elaboration. “Common
humanity” is Neff’s term for that sense of commonality we feel when we
recognize that others suffer as we do: that recognition that we’re all in
the same boat, struggling with “the human condition.” When we
transpose Neff’s three elements onto the hexaflex, “mindfulness” maps
onto defusion (unhooking from self-judgment), acceptance (opening up),
and contacting the present moment (acknowledging your pain); and
“kindness” maps onto values and committed action (kind words and
actions). And if we take self-as-context to mean “flexible perspective
taking,” this is where common humanity goes. Diagramatically, it looks
like this:
 Self-Compassion and the Hexaflex

I think of this diagram as representing the six “building blocks” of

self-compassion. We can work on any one (or several) of these building
blocks at a time; and as therapy progresses, clients can “stack them up”
into stronger, broader repertoires of self-compassion. Let’s take a quick
look at each one.

Acknowledging Pain
The first building block is usually the kind, caring, nonjudgmental
noticing and naming of whatever is painful or difficult. We often need to
distinguish this from self-pity:
Therapist: Acknowledging our pain means being honest with
ourselves about how much this really hurts—without
dwelling on it, wallowing in it, or turning it into self-pity.
So, for example, we wouldn’t say, “This is awful. I can’t
bear it any longer. I’ve never felt so bad. Why me? It’s
not fair.” That’s self-pity, which only makes things
worse. We want to acknowledge our pain in a simple,
kind, and honest way—just as you’d acknowledge the
pain of a friend who was suffering.
 If clients can’t pinpoint the exact feeling(s), we can use terms like
“suffering,” “grief,” “hurt,” “loss,” “pain,” or “heartbreak,” or phrases
like “Here is suffering,” “I’m noticing heartbreak,” or “I’m having a
feeling of emptiness.” And it’s often useful to include terms such as
“here and now” or “in this moment.” When we say, “Here and now, I’m
noticing anxiety” or “In this moment, loneliness is present,” this helps us
to remember that thoughts and feelings are transient—continually
changing, like the weather. Even amid times of the greatest suffering, our
emotions keep changing; sometimes we feel better, other times, worse.
“Here and now” we may be noticing anxiety; later we’ll be noticing a
different emotion.
Other phrases we could use include “This is an instant of,” “This is
a moment of” or “This is an experience of” (e.g., “This is a moment of
great sorrow” or “This is an instant of frustration”). We can encourage
clients to experiment with such words and find a phrase that resonates.
Neff recommends “This is a moment of suffering”—a poetic phrase that
appeals to many. However, some folks prefer more down-to-earth
language, such as “This really hurts.”

Opening Up
When we make room for painful thoughts and feelings, that’s an act
of kindness in itself; it relieves suffering in a way that’s much healthier
than many things we do to avoid it. So any acceptance practice fits
nicely here.

Unhooking from Self-Judgment

Defusing from self-judgment (and its close relatives: self-criticism,
self-loathing, and self-hatred) is a huge part of self-compassion. So any
defusion practice fits nicely here.

Common Humanity
 Common humanity involves the deep recognition that suffering is
something we have in common with all other humans. We acknowledge
and empathize with the pain of others; we consciously recognize that
they too are suffering with their own life difficulties. If we’re fused with
self-pity and the idea that no one else suffers as we do, that not only
fuels disconnection from others, but also ramps up experiential
avoidance. When we recognize the suffering of others, and see our
commonality, this facilitates a sense of belonging and connection, while
also fostering acceptance.
Our repeated normalizing of our clients’ thoughts and feelings,
including our own self-disclosure, lays the ground for common
humanity. However, we need to be careful that it’s not misinterpreted as
trivializing or minimizing the client’s pain:
Therapist: Often when we’re hurting the most, our mind tells
us that we’re alone in our pain—no one else is
going through this—everyone else is happier or
better off than we are! I know that’s often what my
mind says to me; does your mind ever tell you
something like that? (Client agrees.)
The thing is, when we get hooked by that, it
usually just makes us suffer even more. So it’s
often useful to remind ourselves that everybody
hurts, everybody suffers in their own way.
Obviously in different ways, to different extents—
but no one gets a free pass; we’ll all be touched by
loss and hurt and hardship—many, many times in
our lives. But it’s very important that you don’t use
this as a way to discount or trivialize your pain; the
fact is, you’re hurting, and you want to
acknowledge that, not minimize it! The idea is to
acknowledge your pain, and at the same time, see
it as part of being human—something you have in
common with everyone else.
Client: So how do I do that?
 Therapist: Well, one way is to create a phrase to remind
yourself, like “Everyone suffers. This is part of
being human” or “Everybody hurts. It’s the human
condition.”
We then encourage the client to add this phrase to other self-
compassion practices.

THE SKY PERSPECTIVE

Earlier, we aligned common humanity with self-as-context, when
defined as “flexible perspective taking.” But you’ll recall that self-as-
context also means “the noticing self”—and this also plays a role in self-
compassion. When you access the psychological space of the noticing
self, you are like the sky and your cognitions and emotions are like the
weather. So when that weather involves intensely painful emotions,
horrific memories, and harsh self-judgmental narratives, it’s an act of
self-kindness to observe it all from the safe perspective of the sky; to
recognize there’s so much more to you than those terrible events from
the past or those hateful self-judgments; and to let it all flow through
you, instead of consuming you.

Kindness
At the core of self-compassion is the value of kindness. And
although it’s often buried under layers of fusion and avoidance, the Two
Friends metaphor usually quickly uncovers it. Any variant on this
question is usually helpful: “If someone you deeply care about were
suffering like you are right now, what would you say to them, and what
would you do for them?”
If this stumps the client, we can prompt them: “If you wanted to
send them the message ‘I see you’re hurting, I care about you, I’m here
for you,’ what kind of things would you say and do?” (And of course, we
can modify these questions. For example, if the client loves dogs, we
could ask how they’d respond if they saw a dog suffering.) Questions
like this not only tap into kindness, but naturally segue into committed
action.

Kind Words and Actions

Committed action involves translating the value of kindness into
both covert behavior (e.g., kind self-talk, kind imagery, Loving-Kindness
Meditation) and overt behavior (kind, caring, supportive deeds and
actions).

KIND SELF-TALK
Kind self-talk involves speaking to ourselves in ways that are kind,
encouraging, and supportive. This may include anything from validating
our pain (Wow! This is really hard to bear) to compassionate self-
encouragement (I can handle this; I can do this; I’ll get through this).
Any type of question about what you’d say to a friend or loved one if
they were suffering will usually generate ideas. We then suggest:
Therapist: Throughout the day, whenever these difficult thoughts
and feelings show up, the idea is to acknowledge what
you’re feeling, and acknowledge that it’s painful, and
remind yourself to respond with kindness and caring.
And it’s good to have a catchphrase you can say to
yourself. For example, what I say to myself is, This
really hurts. Be kind. So if that appeals to you, you
could use that; but if you want to come up with your
own phrase, that’s even better. Any ideas?
Clients learn to first defuse from harsh self-talk, then say something
kind and supportive. For example, suppose after making a mistake, a
client fuses with “I’m a loser.” Kind self-talk may go like this: Aha.
Here’s the loser theme again. Okay, I know I screwed up. But hey, I’m
human. Everyone makes mistakes.
Perfectionistic clients may remind themselves, I’m having the
thought I need to do this perfectly. And hey, I really don’t have to. “Good
enough” is okay.
Clients struggling to develop a new skill or pattern of behavior may
say to themselves, Here’s the “give up” story—but I’m not buying it.
What I’m trying to do here is really difficult—and today was a bad day.
I’ll have another crack at it tomorrow. Over time, I’ll get better.
Clients who compare themselves harshly to others may say, Aha!
Here’s my mind comparing me again—trying to beat me into shape. And
I don’t have to go along with that. What matters is working on myself,
doing what I care about.
Earlier we talked about cognitive flexibility: defusing from
unhelpful cognitive repertoires and adding in new, more flexible ways of
thinking. We don’t try to ignore, avoid, or distract ourselves from self-
judgmental thoughts; nor do we attempt to dispute or eliminate them; we
accept that they are present (and will continue to recur), unhook from
them…and talk kindly to ourselves.

Practical Tip
Always check the tone of the inner voice. If clients are saying
kind words, but the tone of their inner voice is harsh, sarcastic,
or uncaring, it will not have the desired effect.

KIND IMAGERY AND MEDITATION

There are many imagery and meditation practices that foster self-
compassion. Particularly powerful are “inner child” or “younger you”
exercises, where you imagine yourself traveling back in time to comfort
and care for yourself as a child or adolescent (chapter twenty-nine).
Loving-Kindness Meditation is also very powerful (chapter thirty-one).

KIND SELF-TOUCH
There are many variants of kind self-touch, such as the Kind Hands
exercise in the previous chapter. We encourage clients to experiment and
find what’s best for them. Options include:

One hand on the chest, the other on the abdomen

Both hands on the chest
Both hands on the abdomen
Hugging yourself gently
Hugging yourself while also gently stroking your arms
Gently massaging an area of tension or tightness
Gently holding your face in your hands—plus or minus massaging
your temples

KIND DEEDS AND ACTIONS

The sky’s the limit when it comes to actions of kindness, caring,
and support for oneself: practicing TFACT skills, spending quality time
with others; doing basic self-care such as healthy eating and regular
exercise; making time for rest and relaxation; doing hobbies or sports or
other pleasurable, restorative activities; attending therapy; self-soothing;
and so on.
But note: any activity that’s primarily motivated by fusion or
experiential avoidance is unlikely to function as self-compassion. So it’s
essential that behavior is primarily motivated by kindness and is done in
a flexible, mindful way.
We also explain: “You don’t have to do anything dramatic. Even the
tiniest little act of self-kindness counts.” And if clients are stuck for
ideas, we suggest some. For example, we may use self-disclosure: “To
give you an idea, here are some little acts of self-kindness I did today. I
did some stretching of my back and neck…had a long, hot shower…
played around with the dog, had a laugh with my son watching some
silly YouTube videos…ate some healthy stuff for breakfast. And just
before you got here, I sat outside for a couple of minutes, and closed my
eyes—just to hear the birds and feel the sun on my face.”
 Appreciate
Previously we looked at the four As of acceptance: acknowledge,
allow, accommodate, appreciate. Appreciation plays a huge role in self-
compassion. When clients appreciate the purpose of their difficult
cognitions, emotions, and physiological reactions, this makes a kind
response easier.
Therapist: So this is the crazy thing; when your mind and
body generate all these painful thoughts and
feelings, they’re actually trying to help you. All
those difficult thoughts, painful emotions, fight or
flight, freeze or flop—they all stem from one
overarching purpose: your mind and body trying
hard to protect you, keep you safe.
Client: Yeah well, that may be, but I still don’t like it.
Therapist: Of course you don’t! Who likes pain and
discomfort? No one wants it, no one chooses it.
Life has hit you hard—and your mind and body
responded the best way they know. You didn’t ask
for all this suffering; life dumped it on you. And it
hurts. And when life hurts this badly…we need
some kindness.
Client: (nods thoughtfully) True.

Barriers to Self-Compassion
Let’s now take a quick look at some of the most common barriers to self-
compassion—and how we can overcome them.

Fusion and Getting Overwhelmed

 Even going gently, one building block at a time, self-compassion
may trigger a slew of difficult thoughts and feelings. Clients may
become fused with self-judgment (It was my fault. I deserve what I get)
or overwhelmed by difficult emotions and memories. If this happens,
you know the drill: drop anchor and defuse.

It’s Selfish, Self-Indulgent, or Weak

If clients complain that self-compassion is selfish, self-indulgent, or
weak, we can approach it this way:
Therapist: This kind of work is new and different, so
naturally it’s uncomfortable. And your mind is
trying to help you avoid that discomfort by coming
up with reasons not to do it—it’s selfish or weak.
So how about we let your mind do that…and at the
same time, consider this: if your best friend was
struggling, going through a really tough patch,
would you support them?
Client: Of course.
Therapist: And if they accepted your help and kindness,
would you judge them as selfish or weak?
Client: No…
Therapist: So notice the double standard. If your friend
deserves kindness and caring in their time of
need, so do you.
Client: But that’s different.
Therapist: Of course your mind is never going to agree with
me; it will keep saying this is selfish, this is weak.
So there’s a choice point here. If you let these
thoughts push you around, where does that take
you?
 Client: Back into my hole.
Therapist: Have you ever flown on a plane?
Client: A few times.
Therapist: You know what they say about oxygen masks?
Put your own on first, before you try to help
anyone else? You can think of this the same way:
take better care of yourself so you can take better
care of others.

Motivation
Clients may say, “I have to be tough on myself. That’s what stops
me from screwing up,” or “This is how I motivate myself. If I go easy on
myself, I won’t get anything done.” We want to validate that in the short
term, this can indeed be motivating; but in the long term, it usually has
the opposite effect. The well-known Carrot and Stick metaphor is useful
here:

The Carrot and Stick Metaphor

Therapist: (playfully) You have a pet donkey, right? Carries
your goods to the marketplace?
Client: (playing along) Err, yeah, of course.
Therapist: And there are two ways to motivate that donkey,
right? Beat it with a stick—and it carries the load to
escape the beating. Or coax it with carrots—and it
carries the load to get more carrots. The more you
use carrots, the healthier and happier your donkey.
But the more you rely on the stick, the more
battered, bruised, and miserable your donkey
becomes. So being hard on yourself—is that carrot
or stick?
 Client: Yeah, it’s the stick. But then how am I supposed to
motivate myself?
Therapist: Well, luckily, we have something much better
than carrots—we have something called “values.”
From here therapy segues into learning self-motivation through
values, values-based goals, and compassionate self-encouragement. The
Two Coaches metaphor (similar to the Two Friends metaphor) is often
useful for perfectionistic clients and others who cling to self-criticism for
motivation.

The Two Coaches Metaphor

Therapist: So what’s your favorite sport? (Client answers.)
Okay, so let’s imagine there are two teams of
equally talented players, and they each have a
coach. The first coach motivates the players
through being harsh, judgmental, and critical and
focusing on everything the players do wrong: “That
was pathetic!” “You’re useless!” “You’re not even
trying!” “I can’t believe you did that!” “How many
times do I have to tell you?” “You screwed up this,
you messed up that, and you completely loused up
the other.”
The second coach motivates the players
through kind, supportive feedback and
encouragement, acknowledging what they do right
as well as what they do wrong: “You did A, B, and
C really well today. And I can see you’re improving
at D and E. And I was stoked you remembered to
do H and I when J happened. I notice you seem to
be struggling a bit with F and G; let’s have a look
at what’s going on there, and see how you can
improve on that. Yeah, I know you messed up with
X and Y, but hey—we’re all human; we all make
 mistakes. Don’t beat yourself up about it; let’s go
over it and see what you can do differently next
time something like that happens.”
There are lots of published studies on this topic—
and what we know is that harsh, critical, judgmental
coaching in the long term leads to demotivated
players and poor performance. Kind, supportive
coaching is far more effective; players are more
motivated and performance is better. Have you ever
had a coach/teacher/manager/parent who used the
harsh, critical method with you? What was that like
for you? Which method are you using on yourself?

Religious Connotations
Some people see self-compassion as a religious practice, which can
be problematic, either because they are nonreligious or because they see
it as something from a religion at variance with their own. The easiest
way to avoid this is to introduce it in a nonreligious way (e.g., the Two
Friends metaphor). If, despite this, religious concerns arise, we have an
honest, open discussion about it. We talk about how self-compassion is
an important part of most, if not all, religions; however, these days it is a
widespread secular practice, studied intensively by scientists because of
its benefits for health and well-being.

Little or No Experience of Receiving

Compassion
Some people have had such hard lives, they’ve rarely experienced
genuine compassion from others; and without this, it’s hard to be
compassionate to themselves. We can encourage and support such clients
to:
 Put effort into finding and building relationships with people who
are likely to be compassionate: caring friends, a loving partner,
friendly neighbors.
Join groups or communities or programs—religious, spiritual, self-
development, or self-help—where compassionate support is likely.
Look for and reflect on examples of compassionate behavior in the
outside world, including movies, books, TV shows, friends, and
family.
Practice being compassionate to others, then see if they can do the
same for themselves. Again, Loving-Kindness Meditation is good
for this purpose.

“I Don’t Deserve Kindness”

At times clients may say things like “I don’t deserve kindness.
Other people do, but not me.” (This is obviously linked to larger
narratives around unworthiness.) Rather than challenge or dispute this
idea, we help clients to notice, name, and defuse from it. We may then
ask, “If you follow the rule ‘Never seek kindness, and never expect it,’
what does that help you avoid?” If the client doesn’t know, we explain
that if you never seek kindness, you avoid all that anxiety about whether
or not you’ll receive it. And if you never expect kindness, you avoid
being hurt or disappointed if others don’t treat you well. We can usually
link this to childhood: “In your house, seeking or hoping for kindness
from your caregiver(s) was a recipe for pain and suffering. It was much
safer to give up on it. So this way of thinking is basically your mind
looking out for you.”
From there, a good strategy would be to write the thoughts down:
Therapist: So your mind has issued a decree here: “I do not
deserve kindness.” Is it okay if I write that down?
(Client agrees. Therapist writes it on a sheet of
paper in large block capitals.) And your mind
backs this up with a bunch of other statements,
like “I’m worthless,” “It’s my fault,” “I’m bad.”
 (Therapist writes these under the first statement,
then holds the paper up.) That about right?
Client: Yeah.
Therapist: And I don’t agree with any of these things—but I
think it would be a waste of time trying to debate
that with you, right?
Client: My last therapist tried that—but we didn’t get very
far.
Therapist: I’ll bet. Your mind’s been saying this for such a
long time. Nothing is likely to stop it now. So…
(Therapist places the paper on a spare chair, the
writing clearly visible to the client.)…that’s what
your mind has to say. Basically, the rule is: no
kindness allowed! And you feel you have to go
along with that, right?
Client: I don’t really think of it as a rule. It’s just what I do.
Therapist: Yeah, that’s the thing. (pointing again) You’ve
been doing it for so long, you don’t even see it as
a rule.
Client: It’s who I am. Life’s simpler that way.
Therapist: Gotcha. There are real benefits to living your life
that way. And it’s the same for all of us—when
we’ve been doing things a certain way for a long
time, it’s uncomfortable to even think about the
possibility of doing something different. And so I
want to let you know, I greatly appreciate the effort
you are making.
Client: What do you mean?
Therapist: I mean I’m genuinely impressed that you keep
coming to see me—even though your mind keeps
saying that (points again to the paper). Each time
 you come here, you’re looking after yourself, doing
something to support and take care of yourself.
Every moment we work together here, you’re
breaking that rule (points again to the paper). And
that’s a hard thing to do.
Client: I hadn’t really seen it that way.
Therapist: From where I’m sitting, it’s kind of cool. Is it okay
if we carry on working here, even though your
mind keeps saying that stuff?
Client: Okay.
Therapist: I really appreciate that. What’s it like for you to
be disobeying that rule?
Client: I feel anxious.
Therapist: Yup, that’s a normal feeling to have when you
disobey deeply held rules. It’s almost like breaking
the law.
Client: Yeah, it is.
Therapist: So see if you can open up, let that feeling be
there. (Therapist runs through a quick version of
the NAME exercise. Once the client has accepted
the feeling, the therapist points again to the
paper.) So notice, the rule is still there—but it’s not
controlling you. And if this is the feeling you need
to make room for, to take your life in a better
direction, are you willing to do that?
Client: Yeah.

Opening Old Wounds

 Sometimes as clients start being more self-compassionate, lots of
old “psychological wounds” start to open. This is very painful and can
be overwhelming. Here’s one way to explain what’s happening:

The Orphanage Metaphor

Therapist: Imagine that you’ve taken a job at an orphanage
—one of those old-fashioned ones like you’ve
seen in the movies. And it’s your first night shift.
And you’re walking down the corridor, and you
hear a child crying, in the dormitory. So you go
in…and there are about twenty kids in there, all
fast asleep in their beds—except for this one child,
who’s quietly sobbing into her pillow. So you very
quietly go over to this child and you sit beside her
on the bed, and in a whisper (so you don’t wake
up the other kids) you ask her what the matter is.
And she tells you she’s really sad and scared, and
you say some kind words to comfort her…but, you
just aren’t quiet enough…and two kids on either
side wake up…and they see you there, and they
want your attention too…so they start crying, and
you try to comfort them too…but now the kids
around them are waking up…and they also want
your attention, so they start crying…and before
you know it the whole dormitory is full of kids
crying, telling you how scared and sad they are,
asking you to comfort them.
So if you wanted to help those kids calm down,
feel secure, you’d first need to respond with
kindness and reassurance. If you yell at them or
threaten them, they may get quiet—but they won’t
be calm or secure. And if you run off and leave
them—well, you’ll get some relief, but the kids will
just be hurting even more.
 So you might say, kindly and calmly, “It’s okay,
kids. I’m here, and I’m not leaving you. I’m staying.”
And then you might go around the room, say a few
words of comfort to each child—and promise to talk
later when you have more time.

Most clients get this metaphor without need for further explanation.
We can then refer back to it in later sessions: “This pain you’re feeling
right now—it’s like one of those distressed kids in the orphanage, crying
out for comfort. How are you going to respond?”

Homework
For homework we can encourage clients to practice regularly with any
combination of self-compassion “building blocks.” For one client, we
may focus on kind self-talk. For another, we might encourage daily
practice of the Kind Hands exercise. For yet another, we might
emphasize small daily actions of self-kindness.
We can also encourage clients to create their own mini self-
compassion rituals; for example, do a two-minute version of Kind Hands
before getting out of bed in the morning and before going to sleep at
night; or add it in to dropping anchor.

EXTRA BIT In Trauma-Focused ACT: The Extra Bits

(downloadable from “Free Resources” on
http://ImLearningACT.com), chapter fourteen contains scripts for
a number of self-compassion exercises, including Loving-
Kindness Meditation.

Takeaway
Self-compassion—acknowledging your pain and responding with
kindness—is an intrinsic part of TFACT. Because it can be challenging,
it’s useful to chunk self-compassion into building blocks and introduce
them one or two at a time. Sometimes clients quickly develop this
ability; at other times, it’s painstakingly slow. However, as we say to our
clients, every step counts, no matter how small it may be.
 CHAPTER FIFTEEN.

Knowing What Matters

Although the word “optimism” is rarely mentioned in ACT texts, the

model is inherently optimistic and hopeful. ACT assumes we can all
reduce our suffering and build meaningful lives—no matter where we
have come from, what we have been through, and what we are facing
now. Of course, we don’t teach people to challenge pessimistic thoughts
and replace them with optimistic ones—or to hope all their problems
will magically disappear—but through values and committed action, we
actively instigate a hopeful, optimistic stance toward life.
No matter what’s going on in our life, no matter how hard it may
be, no matter how horrific our past—we can learn how to practice self-
compassion, live by our values, and appreciate what life has to offer.
This doesn’t magically eliminate our pain, solve our problems, and make
us happy—but it does reduce psychological suffering and enable us to
enjoy life more and live meaningfully in the face of our challenges. In
this chapter, we’ll look at the pivotal role of values in helping us achieve
this.

Bringing Values to Center Stage

Values are desired qualities of behavior: the qualities you want to bring
to your actions right now, and on an ongoing basis. One way to describe
them to clients is “your heart’s deepest desires for how you want to
behave as a human being; how you want to treat yourself, others, and the
world around you.” In contrast to goals, which describe outcomes we are
aiming for: what we want to have, get, or achieve in the future, values
describe how we want to behave in this moment and on an ongoing
basis. For example, if you want to “have a great job,” that’s a goal; if you
want to “be responsible and reliable,” those are values. To “get married”:
goal; to “be loving”: value. To “buy a house” for your family to live in:
goal; to “be supportive and caring” toward your family: values. To “go
traveling”: goal; to “be curious, open, appreciative, and adventurous”
while you are traveling: values. To “have a child”: goal; to “be loving
and nurturing”: values. To “make new friends” or “be popular”: goal; to
“be warm, open, and understanding”: values.
If you want power, fame, money, solitude, happiness, popularity,
beauty, respect, a big house, a great body, a flashy car, people to treat
you well or find you attractive—those are all goals, not values; they all
describe outcomes you are seeking, as opposed to desired qualities of
your own behavior.
This distinction matters because even when goals are a long way
off, or seemingly impossible, it’s empowering to live by our values, here
and now. For example, a value such as “being kind” can underpin the
smallest of actions (such as holding a door open for someone) to the
largest long-term goals (such as becoming a therapist). It may take you
years to achieve that long-term goal, but you can live the value of
kindness every day, in a thousand ways, through things you say and do.
We can use values as a compass to guide us through life: to inspire
the goals we set and the actions we take, and to motivate us to do the
hard work of pursuing our goals, even when doing so gives rise to
painful thoughts and feelings. Our values can also guide how we behave
as we pursue our goals, for example, how we treat ourselves and others
as we attempt to get our needs met in relationships. Values hover in the
background of every session—and as therapy progresses, we
increasingly bring them to the foreground.

Gradually Getting to Values

 Let’s quickly retrace our early steps toward values. Often, we first
touch on them in the intake session, teasing them out (without calling
them “values”) from the goals we establish for therapy. Thereafter, we
repeatedly connect with them through the concepts of workability,
towards moves, and choice points. For example, when clients report life-
enhancing behaviors they’ve done outside of session, we may ask, “So
did that feel more like a towards move or an away move?” or “The way
you did that—how would you describe those qualities?” or “What were
you standing for in that moment?” “Did you like who you were as you
handled that?” “Anything you’re proud of in the way you went about
that?”
And when clients talk about their away moves, we ask, “When you
do that, what or who does it take you away from? And what do you miss
out on, or lose?” or “What does that get in the way of?” or “What would
you prefer to do, instead?”
We also tap into values when we explore emotions, with questions
like “What do these feelings tell you that you care about, or need to do
differently? What do they suggest you want to stand for—or against?”
Then, as therapy progresses, we may start explicitly using the word
“values” in our questions: “Which values is this in the service of?” or
“As you practice that skill/pursue that goal/take that action, what values
will you be living?”
Through such interventions, we gather much useful information
about values, values-congruent goals, wishes, needs, desires, important
domains of life, important relationships, behaviors the client wants to
stop or reduce, and behaviors the client wants to start or increase. This is
all golden material for both values and committed action.

Beginning Sessions with Values

When starting sessions with a quick mindfulness exercise, it’s often
useful to flavor it with values. For example:
Therapist: So taking a moment to center yourself…pushing
your feet into the floor…straightening your back…
letting your shoulders drop…fixing your eyes on a
spot…and opening your ears, noticing what you
can hear…with openness and curiosity…sounds
coming from me…and from you…and the room
around us…and outside the room…and now,
consciously tuning in to what you care about, deep
in your heart…reminding yourself of what matters
enough that you made the effort to come here
today…
Therapist: (specifically mentioning values, values-congruent
goals, and important relationships or domains of
life the client has previously mentioned) And
perhaps reflecting on some of the things you’ve
mentioned…like caring for yourself and your
kids…being loving and attentive…being real and
open…being courageous in facing your fears…
getting back into the workforce…and looking after
your health…and taking a moment to
acknowledge, this matters to you…and this is what
our work is all about.

Into the Spotlight

When we wish to bring values into the spotlight, we might say:
Therapist: Can we take a few minutes to talk about
something important? You’ve been working hard,
stepping out of your comfort zone, learning new
skills so that you can unhook from those difficult
thoughts and feelings—and that’s been pretty
challenging, right?
Client: That’s an understatement.
 Therapist: Yeah, it is. And so, I wondered if we could look at
the big picture: where’s all this leading? As I said
on the first session, our ultimate aim is to help you
build a meaningful and fulfilling life. And so far
we’ve been working mainly on one aspect of that
—learning how to deal with difficult thoughts and
feelings. But there’s another really big piece to
this, which is taking action: doing what’s needed to
actively build a better life. So I’m wondering, could
we shift the focus to that?
Client: Okay.
Therapist: Great. So the first step is getting to know what
your values are. And by “values,” I mean your
heart’s deepest desires for how you want to
behave; how you want to treat yourself, others, the
world around you. You’ve already mentioned some
of your values, like… (mentions a few values)…so
I’m wondering, could we explore this in a bit more
depth?
At this point, reactions may vary from openness, curiosity, or
enthusiasm to hopelessness, anger, or cynicism. Negative reactions
indicate fusion or avoidance, and we respond with dropping anchor,
defusion, acceptance, and self-compassion, as we’ll cover in chapter
nineteen. But many clients are receptive. If a client asks, “What’s the
point?” or “How’s that going to help?” it’s important we answer that
question—but we want to keep it short, not give a lecture. We also want
to ensure that the client is genuinely willing to explore values, not just
“going along with it” to please the therapist. Here’s how we might
address both these issues:
Client: I don’t see how that will help.
Therapist: Well, it can help in quite a lot of ways. One, when
we know our values, it helps us make better
choices—do things that work better for us. Two,
they’re like a sort of inner compass that can guide
 us through life, help us to find our way, give us a
sense of purpose. Three, they provide motivation
—give us the strength and courage to do what
really matters. Four, when life is dull and gray, they
add some color to it. And five, when you act on
them, they give you a sense of fulfilment—a sense
of being true to yourself, living life your way,
behaving like the sort of person you really want to
be, deep in your heart.
Client: I don’t have time that for crap. I have real problems
to deal with.
Therapist: Yes, you do. And that’s where we’re headed
next: taking action to solve your problems, to make
your life better. Knowing your values helps you do
that, because they help you choose what you’re
going to stand for, and how you’re going to treat
yourself and others as you tackle these issues.
Client: Yeah, but, look—I can’t just snap my fingers and
rebuild my life. I’ve got a lot of shit to deal with.
Therapist: Yes, absolutely; you have so much shit to deal
with. And you’re so right—rebuilding your life is not
quick and easy. It’s a slow and challenging
process. And it happens through making small
changes, over time—and that’s difficult. And
values give you the motivation to do that hard
work. So, look, I don’t want to push you into this if
you’re not ready. We can certainly spend more
time learning how to handle your thoughts and
feelings, if that’s what you prefer. I mean, I think
you’re ready for this—but I’ll be guided by you.
Client: (sighs) Well, alright then. If you say so, let’s do it.
Therapist: Can I be honest? It sounds like you’re just saying
that to please me. Doesn’t sound like you’re really
 interested.
Client: Well, yeah. I’m skeptical.
Therapist: Skepticism is cool with me. Please don’t believe
anything just because I say it; your experience is
what matters.
Client: Okay. Well, alright then, let’s get on with it.
Therapist: Errm, you know what? I’m a bit hesitant.
Because…it still feels like you’re just going along
with it to please me. And you really won’t get
anything out of it if you do it that way.
Client: So how am I supposed to do it?
Therapist: Well, this is about you. It’s about who you want to
be. Deep inside. What sort of person you want to
be; what sort of relationships you want to build;
what you want to put out into the world in this one
precious life that’s ticking away. Does that interest
you?
Client: (pauses; then answers quietly) Yes.
Therapist: What’s showing up for you now?
Client: (tearing up) I feel kind of sad.
Therapist: That’s a good sign that we’re on the right track.
As clients first start explicitly connecting with values, it’s not
uncommon for their eyes to tear up and emotions such as sadness to
arise. Once we’re sure the client is genuinely willing, we ask them to
pick one area of life they wish to improve (e.g., work, health, leisure, or
an important relationship) and go on to explore values within that
domain.
 Two Surefire Ways to Values
My apologies. The above heading is false. It was a deliberate
attempt to deceive you. The truth is, nothing in TFACT is ever “surefire”
(unfortunately). However, either of the exercises below will help most
people connect with values.

Connect and Reflect

The Connect and Reflect exercise involves thinking about someone
you care about and reflecting on what you like to do together. (It was
inspired by Kelly Wilson’s “sweet spot” exercise, Wilson & DuFrene,
2009.) What follows are bare bones instructions for you to flesh out
with your own words. Go slowly with this exercise, allowing plenty of
time for the client to process each instruction. (They may speak or
stay silent throughout; either is fine.)
There are two parts to the exercise:

Connect and Reflect—Part A

Think of someone you care about who is active in your
life today—someone who treats you well, whom you
like to spend time with. And remember a time, recent
or distant, when you were together, doing an activity
you like.
Make this memory as vivid as possible.
Relive it. Feel it emotionally.
Look out from behind your own eyes onto the scene:
Notice where you are… Time of day?… Indoors or
outdoors?… Weather? Scenery? Temperature?…
What’s the air like? What can you see?… What can
you hear?… What can you touch…taste…smell?
Notice the other person—what do they look like? What
are they saying or doing? What’s their tone of voice,
 the expression on their face, their body posture, the
way they are moving?
In this memory, what are you thinking?… And feeling?
And doing? What are you doing with your arms…
legs…mouth? Are you moving or still? Get into your
body (in this memory); what does it feel like?
Savor the moment. Make the most of it. What’s it like?
Really appreciate it.

Allow the client at least a minute or two to savor the memory.

Then move on to part B, either as a conversation or silently, allowing
the client time to process each question.

Connect and Reflect—Part B

Now step back and look at the memory as if you’re
watching it on a TV screen. Focus on yourself. What
are you saying and doing? How are you interacting
with the other person? How are you treating them?
How are you responding to them?
What qualities are you showing in this memory? For
example, are you being open, loving, kind, fun-loving,
playful, connected, engaged, interested, appreciative,
honest, real, courageous, intimate?
What does this remind you about the sort of person
you want to be; the way you want to treat yourself and
others; the sort of relationships you want to build; how
you want to spend your time?

Connect and Reflect—Debrief

After the exercise, discuss the client’s responses to the questions in
the last two bullet points in part B to highlight the values elicited in
the exercise.
 Connect and Reflect—Modifications
We can easily modify this exercise, asking the client to remember
any activity they enjoy (or used to enjoy) with others or alone—at
home, at work, or at play—and connect with it as above. We then
ask similar questions to those in part B:

What qualities were you showing in this memory?

What does this remind you about the sort of person
you want to be? About how you want to spend your
time?
How do you want to treat XYZ? (XYZ = objects,
people, places involved in the activity)

Whom Do You Look Up To?

Another option is to ask, “Whom do you look up to/respect/admire?”
This could be a historical figure, a fictional character in a book or
movie, someone the client knows personally, or someone they know
about from the media.
Once the client picks someone, we ask questions like “What is it
about them you admire/respect?” “What do you like about their
personal qualities, their personality?” “What are they like as a
person?” “How do they treat other people?” “What do they stand
for?” “If you had to choose two or three words to describe their best
attributes, what words would you use?”
After we have those answers, we can ask, “So are those
qualities you’d like to bring into play in your own life?” If the answer
is yes, we’ve identified values. (This method was used in the WHO’s
ACT protocol. Participants were asked to pick someone in the
refugee camp they respected, then describe this person’s qualities—
especially how they treated other refugees.)
 Practical Tip
You can usually tell when people are truly connecting with
values because they tend to be very present, open, and willingly
vulnerable, with a sense of vitality and freedom. This is often
accompanied by a softening of their face and voice, and
openness in their body posture. So if discussing values seems a
bit stale, dry, or “heady,” this usually means the client is not truly
connecting with them; they’re merely “paying lip service” or
intellectualizing them. To encourage connection, ask them to
imagine living these values: What would it look and sound like?
And how does it feel as they imagine it?

Choosing Values
One of the great things about values is that the moment we choose
them, they are ours. Here’s how we may explain this:
Client: I’ll be honest with you. I want to say “loving” and
“kind,” but when I look at what I’ve been doing, it’s
pretty obvious those aren’t my values.
Therapist: Well, I’m glad you raised that. You see, society
says that what we do reflects our values. But what
research shows us is that a lot of the time, what
we do does not actually reflect our values—
because we get hooked by our thoughts and
feelings and pulled away from our values. You see,
values are “desired qualities of behavior.” They’re
how we want to behave, if we could choose. So if
there’s any value you’d like to have—then by
definition, it’s already your value; it’s a quality of
behavior you desire. If you’d like to be loving, then
being loving is one of your values. If you’d like to
be kind, then kindness is one of your values.
 Client: But I’m not doing anything kind or loving.
Therapist: So you’ve hit on something important: the
difference between values and actions. For any
given value, you can either act on it, or not. If you
want to act on the values of kindness or being
loving, then even if you’ve never done so in your
life, you can start today.

Three Additional Paths to Values

If for some reason the exercises and methods above don’t suit you
or your client, there are many other approaches. Just for good measure,
here are three more:

CONVERSING ABOUT MEANINGFUL

ACTIVITIES
Conversations about activities the client finds meaningful (or used
to) often unearth values. We might ask:

What do you do for fun/leisure/relaxation/entertainment/creativity?

What makes you feel proud/accomplished/fulfilled?
When do you experience a sense of belonging/being fully
alive/doing something important/connecting deeply with someone
or something?
When are you at your best in your marriage/with your family/as a
friend/at work? What are you like to be around at those times? How
do you treat others? How do you treat yourself?

Especially powerful are conversations about “meaningful pain,”

where a client has done (or is doing) something deeply meaningful even
though it was (or is) incredibly painful—such as supporting a loved one
through a serious illness, or standing up for their beliefs and ideals even
though it comes with significant personal costs.
 MONITORING DAILY ACTIVITIES
Monitoring activity is especially useful for clients presenting with
extreme apathy, disengagement, low motivation, or hopelessness. Clients
use worksheets like those in Extra Bits to monitor what they do from
hour to hour, rating each activity for meaningfulness, vitality, and
workability. The completed records raise clients’ awareness of how they
are spending their time and how that affects them, which leads to fruitful
discussions about what enhances life and what drains it.
This is usually our best starting point for deeply depressed or
apathetic clients. It helps them recognize things they are doing that keep
them stuck—paving the way to try something different. They also
discover activities that make life better, so we can explore how to build
on these and tease out the values from beneath them.

VALUES CARDS AND CHECKLISTS

Checklists—such as the one below—are a good way to work with
values in “teacher mode.” First clients select an area of life they want to
improve (e.g., work, education, health, play, parenting, friendship,
intimate relationship). Then they look through or fill in a values
checklist.
FORTY COMMON VALUES

Values are your heart’s deepest desires for how you want to behave as a
human being. They describe how you want to treat yourself, others, and
the world around you. (This is not a list of “the right” values; there are
no “right” or “wrong” ones. It’s like your taste in ice cream. If you prefer
chocolate but someone else prefers vanilla, that doesn’t mean their taste
is right and yours is wrong—or vice-versa. It just means you have
different tastes. So these aren’t the right or best values; they’re just to
give you some ideas. And if your values aren’t listed, there’s room at the
bottom to add them.)
Pick an area of life you want to enhance, improve, or explore (e.g.,
work, education, health, leisure, parenting, friendship, spirituality,
intimate relationship). Then consider which values in the list below best
complete this sentence: In this area of my life, I want to be…
Read through the list, and if a value seems very important in this
area of life, put a V by it. If it’s somewhat important, put an S. And if it’s
not that important, put an N.
In this area of my life, I want to be…

1. Accepting: open to, allowing of, or at peace with myself, others,

life, my feelings, etc.
2. Adventurous: willing to create or pursue novel, risky, or exciting
experiences
3. Assertive: respectfully standing up for my rights and requesting
what I want
4. Authentic: being genuine, real, and true to myself
5. Caring/self-caring: actively taking care of myself, others, the
environment, etc.
6. Compassionate/self-compassionate: responding kindly to myself
or others in pain
7. Cooperative: willing to assist and work with others
8. Courageous: being brave or bold; persisting in the face of fear,
threat, or risk
9. Creative: being imaginative, inventive, or innovative
10. Curious: being open-minded and interested; willing to explore and
discover
11. Encouraging: supporting, inspiring, and rewarding behavior I
approve of
12. Expressive: conveying my thoughts and feelings through what I
say and do
13. Focused: focused on and engaged in what I am doing
14. Fair/just: acting with fairness and justice—toward myself and
others
15. Flexible: willing and able to adjust and adapt to changing
circumstances
16. Friendly: warm, open, caring, and agreeable toward others
17. Forgiving: letting go of resentments and grudges toward myself or
others
18. Grateful: being appreciative for what I have received
19. Helpful: giving, helping, contributing, assisting, or sharing
20. Honest: being honest, truthful, and sincere—with myself and
others
21. Independent: choosing for myself how I live and what I do
22. Industrious: being diligent, hardworking, dedicated
23. Kind: being considerate, helpful, or caring—to myself or others
24. Loving: showing love, affection, or great care—to myself or
others
25. Mindful/present: fully present and engaging in whatever I’m
doing
26. Open: revealing myself, letting people know my thoughts and
feelings
27. Orderly: being neat and organized
28. Persistent/committed: willing to continue, despite problems or
difficulties
29. Playful: being humorous, fun-loving, light-hearted
30. Protective: looking after the safety and security of myself or
others
31. Respectful/self-respectful: treating myself or others with care and
consideration
32. Responsible: being trustworthy, reliable, and accountable for my
actions
33. Skillful: doing things well, utilizing my knowledge, experience,
and training
34. Supportive: being helpful, encouraging, and available—to myself
or others
35. Trustworthy: being loyal, honest, faithful, sincere, responsible,
and reliable
36. Trusting: willing to believe in the honesty, sincerity, reliability, or
competence of another
37. Other:
38. Other:
39. Other:
40. Other:

© Russ Harris, 2020 www.ImLearningACT.com

Forty Common Values Checklist

Clients can obviously redo the checklist above for other areas of
life, and often they’ll find that many values recur across different
domains. Values cards serve the same purpose; usually a pack contains
forty to fifty cards with a different value printed on each. The client
picks a life domain, then sorts the cards into three piles: very important,
somewhat important, and not important. With either method, the client
then chooses two or three “very important” values to “play around with”
(i.e., experiment with various ways of acting on those values throughout
the day) in the week ahead.

Practical Tip
 Many therapists like cards and checklists because they’re easy
to use compared to other methods. However they can become
somewhat superficial or intellectual exercises, where the client
chooses words but doesn’t really connect with them. Therefore,
these methods work best as a second-line intervention, to flesh
out values work after you’ve first done more experiential work,
as above.

Barriers to Values
As with anything in TFACT, at times things will not go smoothly. So
let’s take a look at some common barriers to values.

“I Don’t Know!”
Have you ever had a client who answers, “I don’t know” to every
question about values? If not, you’re lucky! When this happens, rather
than keep asking questions, we might say, “It’s clear that right now, you
really don’t know. So would you be willing to do an exercise to find
out?” We then can then work through a values checklist or do a Connect
and Reflect exercise.
Similarly, when clients say, “I don’t have any values,” we may
reply, “Yes, I can see that’s how it appears. And there are two possible
explanations. One is that you don’t yet have any values; the other is that
you do already have them, but you don’t realize it. And either way, we
can work with that. If you’re willing to do an exercise with me, it will
help you find the values you already have—or create them from scratch.

Confusion with Outcome Goals

Clients often use the word “value” as a synonym for “like” or
“want.” For example, consider these statements: I value financial
security, I value being slim, I value having friends, I value power and
influence, I value inner peace, I value good health. These are not values,
as ACT uses the word; they don’t describe desired qualities of behavior.
They are describing outcome goals—things we want to have, get,
achieve, or complete—whereas values (as mentioned earlier) describe
how we want to behave, here and now, and on an ongoing basis, whether
we achieve our goals or not.
This distinction is important, because we can’t control whether or
not we achieve a desired outcome, but we can control whether or not we
live by and act on our values. Of course, if a desired outcome is
important to us, we can change our behavior to increase our chances of
achieving it—but there is never a guarantee we will succeed. So when
clients identify outcome goals, we want to first validate them, then tease
out the underlying values, and then translate them into action plans.
The following metaphor usually helps clients distinguish between
values and outcome goals:

Where You’re Going and How You’re

Traveling
Therapist: A goal is like a destination—a place you’re traveling
toward, such as Paris or New York. Values are how you
want to behave while you’re traveling—how you want
to treat yourself, and other people, and the things you
encounter along the way. For example, do you want to
be kind and helpful to other travelers, or mean, or
pushy or distant? Do you want be open to and curious
about your experiences while traveling, or closed off
and uninterested? Do you want to treat your body
caringly, or neglectfully? So the goal is the endpoint,
the final destination, whereas values are how you want
to behave along the journey—and how you want to
behave when you get to the end.
 The transcript below illustrates how to shift from focusing on an
outcome goal to identifying a value. The client is a thirty-year-old male
with chronic pain syndrome and PTSD following a physical assault a
year earlier. During the attack, he sustained a back injury, after which he
had spinal surgery, which has only exacerbated the pain:
Client: Look, the one thing I value most is my health. And I
can’t have it! I used to run marathons for fuck’s
sake—now I can hardly fucking walk!
Therapist: I can only begin to imagine how difficult that is.
You look really upset.
Client: Of course I’m fucking upset. Wouldn’t you be?
Therapist: Yes, I would for sure. Anyone would.
(The therapist now asks the client to notice what he’s feeling, and
the client reports sadness and anger. They then do a quick version of
NAME the emotion, incorporating the Kind Hands exercise. The client
has done this before, so no explanation is needed; it takes about four
minutes. The therapist then returns to the topic of values.)
Therapist: So here’s the thing. Of course you want to have
good health—and at this point, you don’t, and
that’s really painful. And one of our aims here is to
get you doing everything possible to improve your
health as much as you can. With that in mind, can
you tell me a bit about how you want to treat your
body?
Client: I want to fix it. I want to get it working again.
Therapist: For sure. And here’s the thing: nobody knows for
sure how long that will take, or how much
improvement there will ultimately be, right?
Client: No.
Therapist: But what we do know is, the better you look after
your body today, the better your chances are for
 the future.
Client: Right.
Therapist: So if you were to really take care of your body—
as it is today—as well as you possibly could, what
would you do?
The therapist has helped to shift the client from the goal of “get my
health back” to the value of self-care (i.e., ”taking care of your body”).
The next step will be to translate this value into committed action—
exploring things the client can do on a daily basis to take care of his
body.

Confusion with Emotional Goals

Sometimes as we work on values, clients fall back on emotional
goals. In the transcript that follows, the client has been focusing on their
relationship with their children and has stated, “I value calm and peace.”
Again, the word “value” is a synonym for “I want”—and the client has
described an emotional goal—how they want to feel—not a value.
Therapist: (making the emotional goal obvious) So you
want to feel more calm, more peaceful?
Client: Yes.
Therapist: Yeah, me too! And you know, what you’re
describing there is what we technically call an
emotional goal—in other words, how you want to
feel. So you want to feel peaceful, feel calm. And I
am so with you on that! I think we all want to feel
calm and peaceful. But of course, it’s impossible to
feel that way all the time—life is stressful and full
of difficulties, and at times we’re all going to
experience anxiety and sadness and anger, and
so on. Remember we talked about how emotions
 are like the weather, always changing—sometimes
wonderful, sometimes dire?
Client: Yeah. I prefer the good weather.
Therapist: Yeah, don’t we all. But the thing is, values are
very different from emotions. Values are not how
we want to feel; they are how we want to behave
—how deep in our hearts we want to treat
ourselves and others and the world around us, no
matter how we are feeling, whether we feel
peaceful and calm or anxious and sad. So
suppose I have a magic wand here—a real one,
that actually does magic. And when I wave this
magic wand, all those stressful thoughts, and
memories, and emotions—are like water off a
duck’s back—no longer hold you back in any
way…then, how would you treat your children
differently?
Client: Err, well—I wouldn’t yell at them all the time.
Therapist: So how would you talk to them when they’re
acting out?
Client: Well, calmly.
Therapist: Okay, so you’d talk more calmly. How else would
you treat them?
Client: Well, I wouldn’t be so hard on them. Wouldn’t be so
strict.
Therapist: So instead of strict and hard, you’d be more
what?
Client: Relaxed!
Therapist: Meaning that you’d relax some of your
expectations for your kids’ behavior? You’d give
them more leeway, more freedom, less demands?
 Client: Err, yeah.
Therapist: So you’d be more easygoing, more flexible?
Client: Yeah, definitely.
Therapist: Anything else? Any other ways you’d treat them
differently?
Client: I guess I’d listen to them more. And laugh more.
Therapist: So you’d be more attentive? More playful?
Client: Err, yeah. We’d have more fun.
Therapist: So you’d be more fun-loving?
Client: Yeah.
Therapist: So you’d behave quite differently toward the kids
—you’d be acting more calmly, more easygoing,
flexible, playful, fun-loving, attentive. So if our work
here could help you to treat your kids that way,
both at times when you feel calm and peaceful,
and also at times when you feel anxious or sad or
angry—would that be useful for you?
We can use the same approach when clients express other
emotional/psychological states they want to have (e.g., confidence, high
self-esteem, relaxation, contentment, fulfilment, satisfaction, joy—or the
classic “I just want to be happy”).
In all these cases, the client’s (usually unconscious) rule is “I have
to first achieve this psychological/emotional state before I can behave
like the person I want to be.” In ACT, we overturn that rule and
introduce a different way of living: I can behave like the sort of person I
want to be—even when I don’t feel the way I want to. (However, if a
client remains fixated on emotional goals, we put values on hold and
return to creative hopelessness.)
 Fusion with Rules
If clients seem rigid, heavy, burdened, or trapped—as opposed to
having a sense of vitality, openness, and freedom to choose—they are
probably fusing with rules rather than flexibly contacting values. The
examples below illustrate the difference:
Being loving = value
I MUST always be loving, no matter what! = rule
Being kind = value
I SHOULD be kind at all times, even when people are abusive =
rule
Being efficient = value
I HAVE TO ALWAYS be efficient, and I MUST NEVER make
any mistakes = rule
Basically, rules are strict instructions you have to obey—usually
readily identified by words like have to, must, ought, should, right,
wrong, always, never, do this, don’t do that, can’t until, won’t unless,
can’t because, and so on. There are countless ways to act upon our
values, in even the most difficult situations. Rules, in contrast, tend to
limit our options and narrow our behavior, and the more tightly we
adhere to them, the less choice we have. Thus, fusion with rules often
prevents us from acting effectively.
In addition, fusion with rules tends to “suck all the life” out of
values. Instead of meaning and vitality, clients fused with rules are likely
to experience pressure, obligation, guilt, shame, or anxiety. Often this
manifests as worrying: “Am I doing it right?” “Am I doing it enough?”
“Am I doing it too much?” So we help clients notice, name, and unhook
from the rules, and return to the underlying values.

Fusion with Reasons

 Fusion with reason-giving often shows up as we do this work. One
form this takes is “I don’t deserve a life.” We could respond to this just
as to “I don’t deserve kindness” in chapter fourteen. Another version is
“I don’t care about anything,” which we respond to as with nihilism, as
in chapter ten.
Sometimes clients use the recurrence of certain thoughts as
evidence that they are a bad person, or that they don’t truly have the
values they profess to (e.g., “I know I say that I want to be about love
and kindness—but that can’t be right because I have all these hateful
thoughts”).
Take the case of Maria, a fifty-four-year-old woman whose twenty-
six-year-old son, Nick, was addicted to heroin. Maria’s trauma stemmed
from multiple distressing incidents involving Nick—including several
life-threatening overdoses, hospital admissions, medical complications,
legal issues, and many aggressive confrontations where he would yell
abusive remarks, threaten violence, or even threaten to kill himself if
Maria did not give him money. At times Maria would have thoughts like
I wish he would just die or We’d be better off if he’d never been born.
These thoughts would then trigger a cascade of self-judgment: What kind
of mother would think that way? I’m horrible, I made him the way he is.
What we’re dealing with here are intrusive thoughts, and we can
help clients respond to them with the methods in chapters ten and eleven.
It’s also helpful to equate these thoughts to ineffective problem solving:
Therapist: This is basically your mind in problem-solving
mode. The problem here is a relationship that’s
causing lots of pain. And the solution your mind
comes up with is “look for ways to end it”—which
includes the other person dying, or an alternative
reality where they never existed. But the thing is,
that’s your mind on autopilot, generating those
solutions. You don’t consciously choose those
thoughts. They just pop up. And the fact that they
distress you tells you something, doesn’t it? Like, if
you really didn’t want him alive, those thoughts
 wouldn’t bother you, would they? The fact they
bother you so much suggests the very opposite.
Client: I never thought about it like that.
Therapist: Yeah, well—it doesn’t stop there. See, first your
mind creates these thoughts and then it starts to
see them as a problem. It’s like, “Hey. These
thoughts are bad!” So now it starts judging you,
telling you how bad you are; it figures, if it can just
beat you up enough, then maybe you’ll stop
thinking that way. But what does your experience
show you; does beating yourself up actually help?
Client: No, it doesn’t.
Therapist: So how about we revisit that self-compassion
stuff?

Experiential Avoidance
Living by our values is a way to make life richer, more fulfilling,
more meaningful. At times this gives rise to pleasurable and enjoyable
feelings—especially when we do so in nonchallenging situations. At
other times, though, acting on our values will trigger painful thoughts
and feelings—especially when we leave our comfort zone to tackle life’s
challenges.
Fear of failure, fear of responsibility, fear of rejection, fear of
making mistakes, fear of the unknown, are all commonplace—as are
many other fears and anxieties. And of course, fear and anxiety are never
barriers in and of themselves, but experiential avoidance often is. If
clients are unwilling to make room for all those difficult cognitions and
emotions, they will resist connecting with or acting on their values. In
such cases, we segue into defusion, acceptance, and self-compassion as
required—and then we return to values.
Clarifying Motivation
When we do things motivated primarily by fusion or experiential
avoidance, they are rarely satisfying—and when we reflect on this
consciously, we are likely to see them as away moves. But If we do those
same things mindfully, motivated primarily by values, they are much
more fulfilling, and we’re likely to consider them towards moves.
For example, if you “want solitude,” that’s a goal, not a value; it
just means you want to spend time alone. Now if this goal is primarily
motivated by fusion with “no one likes me” or avoidance of social
anxiety, then it’s not based on values, and it will likely be an unsatisfying
experience. But if this same goal is primarily motivated by values such
as self-caring, being creative, being mindful, it will be a different—and
much more fulfilling—experience. We help clients to discriminate these
differences not by giving them a didactic lecture, but by guiding them
experientially. In the transcript that follows, the client is a thirty-eight-
year-old woman who spends a lot of her time and energy people
pleasing, and finds it exhausting. But she finds it hard to distinguish this
behavior from acting on her value of helpfulness.
Client: I’m a bit confused, because I think my values pull me
into away moves.
Therapist: Can you give me an example?
Client: Yeah, like one of my main values is being helpful. So
at parties and social events and family get-
togethers, you know, I’ll always be running around
looking after everyone, helping whoever’s running
it—organizing, putting out food, topping up drinks,
helping out in the kitchen—and really, I’m doing it
because it reduces my anxiety. I get really anxious
if I’m trapped in a conversation, or if people ask
me personal things—so it helps me to keep
moving, and it saves me from all that
awkwardness and anxiety.
Therapist: You’ve really highlighted something important
there. Motivation matters. When we do something
motivated by avoidance—trying to avoid difficult
situations, thoughts, and feelings—it’s not
satisfying. And that’s what you’re describing.
When we do something motivated by values, it’s
different. Have you ever done something helpful
not to avoid anxiety or awkwardness, but just
because you really wanted to, deep in your heart?
Client: Oh yeah. Like, my Gran—she’s in a hospice—and I
go visit her every couple of weeks and take her out
in her wheelchair.
Therapist: And what’s that like?
Client: It’s nice. You know, she was always really kind to
me, when I was little. But it’s hard—it’s sad to see
her like she is now.
Therapist: And so even though you know you’re going to
feel sad, you visit her?
Client: Yeah, well—she’s my Gran!
Therapist: And when you’re doing that—does it seem like
you’re being the person you want to be?
Client: Oh yes.
Therapist: And what about when you’re running around at a
party, avoiding getting trapped in conversations;
does that seem like you’re being the person you
want to be?
Client: No.
Therapist: Right. So helping out your Gran—that’s living
your values. Helping out at the party—well, the
value’s still there, but it’s kind of in the background,
isn’t it? I mean, what’s driving you most?
 Client: Yeah, trying to avoid anxiety.
Therapist: Yeah. Big difference.
In trauma literature, we often read about “survival strategies,” “co-
dependent behavior,” “people pleasing,” “fawning,” “submissiveness,”
and so on. But when we look at these behaviors through a TFACT lens,
we see they are all primarily motivated by fusion and experiential
avoidance. My favorite interventions to distinguish these motivations
from values are all variants on the magic wand question:

If I could wave a magic wand so that everyone on the planet

automatically loves you, treats you well, and approves of
everything you do—no matter what you do—would you still go
ahead and do this? Or would you do something different?
If I could wave a magic wand so that there’s no chance of failure,
no chance of things going wrong—all those things you’re most
afraid of, they can’t possibly happen—would you still do this?
If I could wave a magic wand so that you had no fear—would you
still do this?
If I could wave a magic wand so that all those rules about what you
should or shouldn’t do, or the “right” thing to do, or what you’re
supposed to do, or what others expect you to do—they lose all their
power over you, they no longer dictate what you do—would you
still do this?

Let’s continue the transcript from above, to see how we can use
such questions in session:
Therapist: So if I could wave a magic wand so that next
time you’re at a party you behave like the sort of
person you really want to be, deep inside, and
nothing stops you from that—no thoughts, no
feelings; nothing can stop you, because this is
magic, right?—how would you behave differently?
Client: Well, I’d still help out, because…I like helping out.
Therapist: Would you help out as much as before?
Client: No, probably not.
Therapist: So what would you do instead, if you weren’t so
busy helping out?
Client: I’d talk to people more. You know, get to know them.
Therapist: And let them know you?
Client: Ooh, that’s scary.
Therapist: But this is magic, right? If magic happened, so
fear lost all its power over you…
Client: Yeah, I’d let them get to know me a bit better.
Therapist: And what values would that be living—if you talk
to people, get to know them and let them know
you?
Client: Err, I’m not sure…
Therapist: Would it be any of the values on that list?
Client: (scanning the list) Ummm…genuine…open…
trusting…
Therapist: Courageous?
Client: Yes!
Therapist: So if our work here could help you to do that, that
would be useful?
Client: I don’t think I could.
Therapist: You look worried.
Client: I am.
Therapist: What’s showing up for you?
Client: I’m scared.
(The therapist takes the client through a brief
NAME exercise to make room for anxiety, then
continues.)
Therapist: So even thinking about acting on those values
brings up anxiety, right? And your mind doesn’t
like that. So what does it tell you to do?
Client: Don’t do it!
Therapist: Yep, follow the rules. And your mind has laid
down some very clear rules about what you can
and can’t do. Let’s go through them. Number one
is, obviously, “Be helpful!” What are some others?
Client: Well, don’t talk to anyone for too long. Keep moving.
Therapist: Yeah. And what are you allowed to talk about?
Client: Oh, just jokes or small talk.
Therapist: And you’re not allowed to talk about…?
Client: Personal stuff. Nothing deep or meaningful.
Therapist: And what does your mind threaten you with, to
stop you from breaking those rules? What does it
warn you will happen?
Client: Oh you know, they’ll find out what I’m really like.
Therapist: And then?
Client: And then they won’t like me.
Therapist: And then?
Client: Well, they won’t want to know me.
Therapist: And then?
 Client: I’ll be alone.
Therapist: And that’s a pretty big threat, isn’t it?
Client: Yeah.
The therapist has now identified the fusion and experiential
avoidance that motivates the client’s behavior and identified the values
they’ve “lost.” There are many ways to go from here: exploring ways to
act on those values (openness, honesty, trusting, and courage) in social
situations; defusion from rules; making room for the anxiety that will
inevitably accompany these new behaviors. If time allows, the therapist
can also explore the client’s comment “They’ll find out what I’m really
like”: tease out fusion with self-judgment, and move into self-
compassion. (If there’s insufficient time, the therapist would follow this
up in the next session.)

Homework
For homework, we could ask clients to reflect on their values, write
about them, talk about them with a loved one. We could also ask them to
track when and where they act on their values, and what happens when
they do so. (See the various homework worksheets in Extra Bits.)
If, however, the client is already clear on at least some of their
values, we can ask them to nominate an area of life (e.g., work,
relationships, health, or leisure) and specify two or three values to “play
around with” in that domain. Alternatively, we can invite them to
experiment with “flavoring and savoring” (Harris, 2015).

Flavoring and Savoring

Therapist: Each morning, choose one or two values that you
want to bring into play throughout the day. So, for
example, you might pick “playfulness” and “openness.”
You can choose different ones each day, or always
 keep them the same—up to you. Then, as you go
through your day, look out for opportunities to “sprinkle”
those values into your activities—so whatever you’re
saying or doing, see if you can give it the flavor of
those values. And as you flavor it, savor it! You notice
what you’re doing and you actively savor the
experience—just like savoring your favorite food or
music—you tune in, notice what’s happening,
appreciate it.
Most clients respond well to this suggestion, but a few have
great difficulty with “savoring,” which indicates the need to work on
mindful appreciation skills, as in chapter twenty-seven.

EXTRA BIT In Trauma-Focused ACT: The Extra Bits, chapter

fifteen, you’ll find values checklists, information about values
cards, activity-monitoring worksheets, various homework
worksheets, the “Bull’s Eye,” and the “Life Compass.”

Takeaway
Values are the foundation of the whole ACT model. Like a compass,
they give us direction, keep us on track, and help us find our way when
we get lost. Clients often find it hard to connect with their values
because they are buried under layers of fusion and avoidance. This is
especially so with clients who are disconnected from their feelings or
have an impoverished sense of self. But over time, with gentle, patient
persistence—and huge amounts of understanding and compassion—we
can usually get there. We may discover values hiding in many places,
especially in narratives about what’s lacking or missing, in experiences
that give a sense of vitality and meaning, and in the important messages
carried by painful emotions. Once values are unearthed, they become a
powerful source of motivation and inspiration for the difficult work of
building a meaningful life.
 CHAPTER SIXTEEN.

Doing What Works

The dual aims of TFACT are to reduce psychological suffering and build
a meaningful life. To achieve these outcomes requires committed action:
living by and acting on our values, in ways both great and small.
Committed action is a truly huge umbrella; it encompasses not only goal
setting, action planning, problem solving, and formal exposure, but also
any type of empirically supported behavioral intervention, from
behavioral activation for depression to social skills training for
interpersonal problems.
The brunt of work in this stage involves helping our clients to
reclaim, open, or expand important areas of life they’ve been avoiding,
and most sessions have a dual focus on (a) translating values into
actions, and (b) overcoming barriers. In the first part of this chapter,
we’ll review the main elements of this work; in the second part, we’ll
look at a transcript that illustrates them; and in the third part, we’ll cover
strategies to facilitate committed action despite the many challenges of
trauma.

From Values to Actions

In a typical session, we invite clients to select a domain of life or a
problem to work on and choose the values they want to put into play. We
then help them set goals, create action plans, and implement them. In
some cases, this may involve abandoning areas of life that are toxic (e.g.,
ending an abusive relationship, leaving an unsafe workplace, or staying
away from people and places that facilitate problematic drug use). As
you’d expect, such work usually triggers painful thoughts and feelings,
so we often have to segue into defusion, acceptance, or self-compassion,
and then return to the task at hand.

Useful Questions for Goals

After asking the client to pick a life domain they wish to improve,
or a specific problem they’d like to address, we can ask questions such
as:

What values do you want to bring into play here?

What do you want to stand for?
What do you want to be about in the face of this?
Who do you want to be as you address this?
What do you want to model for others?

The client identifies one to three values they want to bring into play,
which we then use to set SMART goals. There are various versions of
the SMART acronym; I prefer the following:
S—Specific
M—Motivated by values
A—Adaptive
R—Realistic
T—Time-framed
(If you’re not familiar with these terms or are unsure how to set
SMART goals, see Extra Bits.)

Goals into Action Plans

 Next, we break those goals down into action plans:

When and where will you do this?

What’s the first step? And then what? And then?
What equipment, resources, and skills will you need?
What unhooking skills will you need?
On a video, what will that look like and sound like?

Often, we can “cut out the middleman”: move directly from values
to actions without the intermediate step of goal setting. (We did this in
the WHO protocol because we thought goal setting would add an
unnecessary level of complexity. This is also a good option for clients
who dread, resent, or feel overwhelmed by setting goals.) If we follow
this path, then after choosing values, we ask, “So what are some small,
simple actions you can take straight away, to start living these values?
Little things you could say and do, not too demanding?” And we
emphasize “thinking small”:
Therapist: You know the saying “The journey of a thousand
miles begins with one step”? So let’s think small here.
What’s the smallest, easiest step you could take?

LONG-TERM GOALS
Initially TFACT focuses on short-term goals and action plans: what
do you want to achieve in the next few hours, days, or weeks? But later,
we look at longer-term goals, such as finding a partner or changing
career. (Of course, it doesn’t have to be that way around; we can look at
long-, medium-, or short-term goals at any point in therapy.) When
breaking these goals down, we have the client consider: What do I need
to start doing right now to have the best chances of achieving this in the
future? What short-term and medium-term goals will take me closer
toward it?
So, for example, if a client has a long-term goal of finding a partner,
short-term goals may include researching and joining dating platforms,
starting new activities where they are likely to meet suitable people, or
maybe even working on social skills. Medium-term goals may be going
on dates or sharing activities with potential candidates. Similarly, if the
long-term goal is to find a new job or change career, short-term goals
may be researching different work options, seeing a career counselor, or
writing a resume. Medium-term goals may be learning new skills,
getting work experience, or going for interviews.

VALUES-BASED PROBLEM SOLVING

Problem solving in TFACT differs from other models because it is
explicitly values based. Thus, after defining a problem, we explore:
“What do you want to stand for in the face of this?” or “What values do
you want to bring into play?”
From there, we follow all the traditional steps of formal problem
solving. We brainstorm possible courses of action, consider the pros and
cons of each, and combine the best ideas into an action plan. We then
implement it, track the results, and modify it as needed—depending on
what worked and what didn’t. (The challenge formula comes in very
handy here.)

ANTICIPATING OBSTACLES
Once clients have established an action plan, we ask, “Can you
think of anything that might get in the way of this?” We then help them
figure out how to deal with those obstacles, should they arise.
It’s wise to explore a “fallback option” or “contingency plan”; if a
particular course of action can’t be pursued for one reason or another,
there are always many other ways to act on the underlying values. But
without planning ahead, clients may not realize this. So we may ask,
“You know that saying, ‘The best laid plans of mice and men often go
awry’? If this all goes pear-shaped, what’s your plan B?”

Willingness
 Willingness is essential. We check repeatedly that clients are willing
to take action—even if it’s scary, painful, and difficult. We remind them
that they don’t have to do it; it’s a personal choice. And we ensure it’s in
the service of their own values and goals, as opposed to pleasing or
complying with the therapist.
Earlier we looked at “willingness” as a synonym for acceptance: the
willingness to make room for your thoughts and feelings, in the service
of living your values (as opposed to reluctantly or half-heartedly making
room for them, which we call “tolerance”). Here “willingness” refers to
a quality of behavior: doing things willingly as opposed to resentfully or
begrudgingly. And we need to clearly distinguish “willing” from
“wanting”:
Client: I don’t really want to do it.
Therapist: Of course you don’t. It’s bringing up a lot of
uncomfortable thoughts and feelings. And you
don’t have to do it. The question is, is it important
to you? Are you willing to do it, even though you
don’t want to?
Client: I don’t see the difference.
Therapist: Well, suppose I had cancer. Now I do not want to
have chemotherapy or radiotherapy or surgery—
but I’d be willing to have them in order to cure my
cancer. So if something is important, we can be
willing to do it even though we don’t want to do it.
Have you ever done something resentfully or half-
heartedly?
Client: Yeah.
Therapist: So that’s the opposite of willingness. And did you
notice how dissatisfying it was?
Client: Yeah. I get it. But I don’t feel willing to do it.
 Therapist: Yeah, for sure. Because willingness isn’t a
feeling. It’s more like an attitude: “This matters to
me, I care about this—so I’m prepared to do it
even though I have lots of uncomfortable feelings,
and lots of thoughts about not doing it.”

MOTIVATION
Given that new behavior is challenging, motivation is an important
aspect of willingness. This is where values come into their own. Like the
mythical philosopher’s stone that transforms base metals into gold,
values can turn any activity into something meaningful and intrinsically
rewarding. With this aim in mind, we can ask:
So when you do this, will it be…

a towards move/taking you closer to the bull’s eye/moving toward

the life you want to build?
doing something new/trying something different—rather than doing
the same old thing/staying in the rut?
getting closer to/more in line with the sort of person you want to be,
deep in your heart?
likely to have any benefits for you or the people you love?

Monitoring and Scheduling

In the previous chapter we discussed encouraging clients to monitor
their daily activities and gauge them in terms of vitality and workability.
This provides a lot of valuable information about what the client does
that is workable—and what they do that isn’t. It’s often a great
springboard for committed action: the idea is to do more of the behaviors
that are workable, and explore alternatives to the ones that are not.
Hand-in-hand with monitoring goes scheduling. We encourage
clients to fill in worksheets (see Extra Bits) to schedule life-enhancing
activities for the week ahead. This advanced planning instigates and
maintains positive behavior change and is especially important for
clients who are apathetic, demotivated, or depressed. If they don’t plan
ahead, they often find themselves spending time in unfulfilling ways.
Scheduling can be done anywhere from a day to a week in advance—and
the more planning and organizing an activity requires, the earlier this
should start.
If clients have no idea of meaningful things to do with their time,
this itself plays a big role in maintaining or exacerbating their suffering.
In such cases, we can present them with a list of pleasant activities.
(You’ll find one in Extra Bits, but a google search for “list of pleasant
activities” will give you lots of alternatives.) As therapy progresses, we
can help clients engage mindfully in these activities while defusing from
and accepting the difficult thoughts and feelings almost certain to arise.
Exploring and Experimenting
“If you always do what you’ve always done, you always get what
you’ve always gotten.”
This quote by Jesse Potter (often erroneously attributed to Henry
Ford) speaks to the problem of behavioral rigidity. When facing difficult
situations, behavioral variability is (usually) adaptive—but our default
setting is to fall back into long-established patterns. And on occasion,
that may be effective. But very often, by the time clients come to
therapy, they are stuck in narrow, rigid repertoires of behavior that are
not working to give them the results they want; and often, they aren’t
even aware of this.
So we encourage them to explore other options, experiment with
new and different ways of doing things. And inevitably, this is risky.
When we step out of our comfort zone and try new things, there’s always
a risk of failure. There are no guarantees. Things may go wrong; things
may backfire; things may even get worse. So anxiety—and all the
reason-giving that goes with it—is virtually guaranteed, and we
repeatedly normalize and validate it. And we ask, “Are you willing to
make room for these difficult thoughts and feelings, in order to do what
matters?”
And what if the client is not willing? Glad you asked.
 THE HARD BARRIERS
Again and again, as we do this work, we will push up against the
HARD barriers:
H—Hooked
A—Avoiding discomfort
R—Remoteness from values
D—Doubtful goals
H = Hooked
Clients will repeatedly get hooked by reason-giving: their minds
will come up with many different reasons for why they can’t, shouldn’t,
or shouldn’t even have to take action: “I don’t deserve a life,” “I’ll only
fail if I try,” “Something bad will happen,” “I’ll get hurt,” and so on.
The antidote is defusion—especially notice, name, normalize,
purpose, workability. The mind’s main “purpose” for virtually all forms
of reason-giving is protection: saving you from pain, keeping you from
taking risks. And the workability question is always some version of “If
you let those thoughts dictate your choices, where does that take you?”
We may add, “You can’t stop your mind from saying these things, but
you can unhook from them.”
A = Avoiding Discomfort
Personal growth and meaningful change means stepping out of your
comfort zone. This inevitably brings up discomfort in the form of
difficult thoughts, sensations, emotions, memories, and urges. If clients
aren’t able to open up and make room for these experiences, they won’t
do the things that really matter. To overcome this barrier, we do more
work on developing or applying acceptance and self-compassion skills.
R = Remoteness from Values
Why would clients bother to do this challenging stuff if it’s not
important or meaningful? If clients are ignoring, neglecting, or forgetting
their values; or being pulled away from their values by fusion (e.g., with
rules); or merely paying lip service to certain values to please the
therapist, then they will not have the desired effect. The antidote is to
help clients truly identify and connect with their values, and recognize
they will be living these values with every step they take.
D = Doubtful Goals
As mentioned in chapter nine, after agreeing on an action plan, it’s
useful to gauge how realistic it seems, on a scale of zero to ten. If a client
scores less than seven, it’s doubtful they will follow through. So we
explore: Are their goals excessive? Are they trying to do too much, or do
it too quickly? Or perhaps even trying to do it perfectly? Are they trying
to do things for which they lack the resources (such as time, money,
energy, health, social support, or necessary skills)?
If so, we change the goals: make them smaller, simpler, easier, and
matched to the client’s resources—until the client’s realism score goes
up to at least seven.
The idea is to run through these common barriers with the client,
see which ones are relevant, and come up with plans to deal with them.
(In Extra Bits, you’ll find a HARD barriers worksheet.)

Transcript: Therapy Session with Mark

This is an extract from session six with Mark, a thirty-four-year-old
former army officer. Mark developed PTSD after a tour of duty in which
his friend was shot through the head and killed. He has since left the
army. He lives by himself, has become socially withdrawn, and feels
intensely lonely. In line with his values of “courage, self-care, and
friendship,” he wants to reestablish social contact with friends and
family. He would like to start by reaching out to his oldest friend, Jake.
Therapist: Any hesitation about doing this? Does anything
show up for you when you talk about that as a
possibility?
 Client: I guess there is a little bit of um, a resistance,
because you know, I don’t want to have to talk
about stuff too much and I also feel, like,
embarrassed that I haven’t kept in contact.
Therapist: So those are valid concerns. Do you notice
anything happening in your body right now?
Uncomfortable feelings?
Client: Yeah. Got like a, like a pain in my gut here.
Therapist: What’s it like in there?
Client: Like tight or something.
Therapist: Tight? And what kind of shape and size?
Client: Like a ball. (uses his finger to draw a circle around
his abdomen)
Therapist: And what would you call this feeling?
Client: Maybe, like fear or something?
Therapist: Fear? Well, that’s to be expected. As we start to
talk about making changes in your life to build a
new future, there will probably be a lot difficult
thoughts and feelings showing up.
(The therapist takes the client through a ninety-second NAME
exercise to help him accept the fear. Following this, they explore reason-
giving…)
Therapist: So as we’ve discussed before, your mind is like a
reason-giving machine, and it’s going to crank out
a whole lot of reasons not to do this. Can I get you
to jot some of these down?
Client: Okay.
(The therapist prompts the client to identify reason-giving, with
questions such as “How’s your mind trying to talk you out of this?”
“What’s it warning you might go wrong?” The client writes down each
reason on a sheet of paper. This continues for three minutes. The
thoughts include: Don’t want to talk about what happened, He’s moved
on, He’s got no time for me, We’re too different, He won’t want to talk to
me, I’m too fucked up, I’ve got nothing to say, He’s got a life and I
haven’t, I got nothing, I am nothing. I’m going nowhere.)
Therapist: There we go. So your mind’s really doing a
hatchet job, isn’t it? “I got nothing. I am nothing.
I’m going nowhere.” And my guess is this isn’t
unique to Jake; your mind would say this if you
think about reaching out to just about anyone.
Client: Yeah, it would.
Therapist: I mean, there might be a few little tweaks on the
theme, but it’d basically be “I’m nothing, got
nothing, they don’t want me, I don’t like talking…”
Client: Probably, yeah, yeah.
Therapist: (pointing to the paper) So how are you going to
unhook from that?
Client: Um…I can call it the “Don’t Do It!” story?
Therapist: Sounds good to me. Can I get you to write that
on the back?
(On the back of the paper, the therapist asks Mark to write, in large,
bold letters: Aha! Here it is again! The “Don’t Do It!” story. Thanks,
mind. I know you’re trying to save me from pain—but it’s okay—I’ve got
this handled. [Mark has already used these techniques in previous
sessions.] The therapist asks Mark to silently read to himself all the
negative thoughts written on the paper—and emphasizes, “And see if
you can really let them hook you.” The therapist then asks Mark to flip
the paper over and silently read the statement on the back. Mark finds
this very helpful: his score on the fusion scale [chapter ten] drops from
an eight to a three.)
Therapist: So all of this stuff—these thoughts and feelings:
fear, embarrassment, pain in the stomach, self-
judgment—I predict they’re going to keep showing
up as barriers, to stop you from doing the stuff that
makes your life better.
Client: I think you’re right.
Therapist: Any idea what your mind might be trying to save
you from?
Client: Um yeah, embarrassment? Fear? Failure?
Therapist: Yup. Fear, embarrassment, getting hurt. So your
mind’s a lot like my mind; this is what they do to
protect us. And there’s a choice here. Do you give
up on doing the stuff that’s important, because of
all these difficult thoughts and feelings, or do you
make room for them, and do what really matters?
Client: I’m not giving up.
Therapist: What are you going to do?
Client: I’m going to call him.
Therapist: You know, my mind’s telling me you’ll think this
sounds corny, but the truth is, I feel privileged to
hear you say that. I mean, I can see that this is
painful for you and I know you’ve been through an
incredibly rough journey and I can see your mind
generating all of these reasons to give up—and
yet you’re willing to keep going. That’s inspiring.
Client: Thanks.
Therapist: So what’s the very first step?
Client: Um, well, just pick up the phone, I guess.
Therapist: Okay. So I’m going to put you on the spot here.
I’m going to ask you a question, and before you
answer I want you to just use that noticing part and
just notice what your mind says and notice what
feelings show up in your body. Okay? So the
question: When are you going to call him? Give
me a day, date, time. Take a few seconds. Just
notice what your mind says. Notice what feelings
show up in your body.
Client: Okay.
Therapist: What are you noticing in your body?
Client: Uh, my stomach went a bit tight. There are bits that
are like jumpy.
Therapist: What did your mind say?
Client: It’s just like scanning for I don’t know… Is he going
to be available? Will he pick up? What will we do?
Therapist: Can I get you to jot those things down too,
please? Will he be available? Will he pick up?
What will we do? (Mark writes them down.) And
how would you describe this feeling?
Client: Um, worried.
Therapist: Worried? So if that’s showing up right now just
talking about it, we can pretty much guarantee it’s
going to show up in the real situation.
Client: Yeah, you’re right.
Therapist: Are you willing to make room for this stuff?
Client: Yes. Yeah for sure.
Therapist: Cool. So let’s plan it. When are you going to
make the call? Day, date, time?
Client: Okay, say Wednesday, after work—about sixish.
Therapist: So, let’s role-play it. I’ll be Jake. You pick up the
phone. Just kind of…let’s just kind of play with this.
You’ve kind of, you’ve got the phone there and I’m
Jake. (Client and therapist both pretend they are
talking into cell phones.) Uh, hello?
Client: Hey, Jake, how are ya?
Therapist: Uh, who’s this?
Client: It’s Mark.
Therapist: Mark…Mark! Okay!
Client: Hey, buddy, what’s going on? Long time!
Therapist: Wow. It is a long time. What the fuck happened
to you?
Client: (awkwardly) Err…yeah…well, err…
Therapist: Okay let’s pause. What’s showing up?
Client: Uh, a bit embarrassed, a bit of fear, a bit of I don’t
know what to say.
Therapist: Okay. What was your mind actually saying while
you were talking to Jake?
Client: Uh, you know, this is stupid. Hang up.
Therapist: Well, that’s what your mind’s going to say on the
day. So I’m wondering, is it worth maybe
rehearsing a bit—preparing what you’re going to
say?
Client: Yeah I could um, I could just you know practice
maybe what I’m going to say—like where I’ve
been, why I didn’t keep in touch.
 Therapist: Great. So let’s say you chat with him for a few
mins, and then…what are you going to ask him?
Like, are you going to suggest catching up, doing
something together?
Client: Uh, yeah—maybe see if he wants to go for a beer or
play some basketball, shoot some hoops.
(They now role-play this part of the conversation, and again the
therapist asks Mark to check in, see what’s showing up. Once again,
Mark reports embarrassment and anxiety and thoughts about backing
out.)
Therapist: So in the service of those values of courage,
self-care, and friendship, are you willing to make
room for all of that?
Client: Yes I am.
Therapist: On a zero to ten scale, how realistic is it that you
will do these two things: (a) go home and rehearse
and plan this conversation, and (b) actually make
that phone call on Wednesday at 6 p.m.?
Client: Uh…I’d like to say ten but uh, I would say,
realistically, about eight.
The transcript above illustrates the two key themes of this chapter:
translating values into goals and actions, and overcoming HARD
barriers. Note the use of role-play to bring the action plan to life, and the
repeated segues into defusion and acceptance.

Additional Strategies for Committed

Action
With trauma-related disorders, there are often many barriers to
committed action, so we typically need multiple strategies to help clients
do what truly matters to them. In this section, we’ll explore several
options; the idea is to add these on to the methods we’ve already
covered.

Savoring and Appreciating

In the last chapter, we discussed “flavoring and savoring.” We can
extend this practice to all committed action, on an ongoing basis, by
repeatedly tuning in to underlying values and mindfully appreciating
what happens as a result. This plays a big role in ongoing motivation.
For example, many clients with trauma-related disorders suffer from
high social anxiety—especially with regard to fear of negative
evaluation. Social withdrawal is understandably common. But even
when clients do attend social events, they often “white-knuckle” it:
“tough it out” and “get through it” with little or no satisfaction or
enjoyment. Afterward, they typically judge the event—and their own
social “performance”—extremely negatively: “It was horrible,” “a waste
of time,” “hated every minute of it,” “I was useless,” “I couldn’t talk to
anyone,” “I hid in the corner,” and so on. Naturally, this bodes poorly for
future socializing.
So when such clients attend social events, we can encourage them
to notice and appreciate all those little moments where they manage to
make eye contact (even fleetingly), or share something personal, or
establish a sense of connection. That way, even if the overall experience
is stressful and dissatisfying, there are moments within it they can
appreciate. And over time, as their skills improve, they are likely to have
more of those meaningful moments. (Of course, mindful appreciation is
a skill that usually requires formal practice: see chapter twenty-seven.)

Cognitive Flexibility and Committed

Action
As discussed earlier, ACT helps people not only to defuse from
unhelpful cognitions but also to develop new, more effective ways of
thinking. Let’s quickly look at three types of flexible thinking that
TFACT encourages to facilitate committed action: reframing,
reinterpreting, and motivational self-talk.

REFRAMING
“Reframing” means looking at something from a different
perspective, which then changes the way you respond to it. TFACT is
full of reframing—especially about what’s in our control and what isn’t.
For example, at times clients fuse with thoughts like I’ll fail or It won’t
work. After normalizing those thoughts, we often present this reframe:
“The truth is, we have no control over whether we will achieve a goal or
not, but we do have a lot of control over the actions we take to try and
achieve it. So even though there are no guarantees, we can give it our
best shot. And if we fail, at least we know we tried. But if we give up
because our mind says, ‘It won’t work,’ then that’s obviously not taking
us toward the life we want.”
Sometimes, clients get hooked by the narrative “I can never have
the life I want,” and often they can back this up with incontrovertible
evidence based on their past trauma history. If so, we validate that the
life they have is not the one they wanted, and we help them make room
for the painful feelings that are inevitable and practice self-compassion.
After much validation, and with great compassion, we may help them
reframe this situation: “It’s truly awful what you’ve been through. No
one should have to experience that. The question is, what next? Where to
from here? You probably know that old saying: ‘We don’t get to choose
the deck of cards life deals us—but we do get to choose how we play
them.’” In other words, the challenge now for the client is how to make
the most of the life they have—even though it’s not the one they want.
At other times clients may protest, “It’s too late.” In this case, a
useful reframe is that old Chinese proverb: “The best time to plant a tree
was twenty years ago; the second best time is now.” In other words, we
agree, it would have been better to start earlier—but that’s not in the
client’s control; what is in their control is to take action now. (We could
add, “Your mind will keep saying it’s too late—and every time it says
that, there’s a choice for you to make.”)
 REINTERPRETING
The more difficult, challenging, or threatening a situation, the more
likely it is to trigger fusion with judgments, themes, rules, reasons,
schemas, or core beliefs. And in turn, that fusion shapes the way we
interpret the situation. All too often, our initial automatic interpretation is
unhelpful—in the sense that it doesn’t help us to act effectively, guided
by our values; rather, it triggers self-defeating patterns of behavior. So
when clients face these situations, we encourage them to drop anchor
and unhook from that first interpretation, and consider alternative
perspectives that can help them to handle it better. In other words: “How
can I think about this differently, in a way that’s going to help me act
effectively?”
For example, a client prone to aggressive verbal behavior is very
anxious and furious because her partner is three hours late in returning
home from work. While dropping anchor, she might say to herself
something like My mind’s in judgment mode, or My mind’s telling me she
did this on purpose to hurt me, or Here’s the “She doesn’t care” theme!
She makes room for her anger and anxiety and reminds herself of the
values she’s been working on: being kind, patient, and understanding.
She thinks to herself, If I let myself get hooked by “She doesn’t
care,” I know what’s going to happen. I’ll start shouting, yelling,
blaming as she comes through the door, and we’ll have a huge fight. I
don’t want that. My values are kindness, patience, and understanding.
How would a kind, patient, understanding partner interpret this
situation?
She may then consider, It’s not really her fault; other people
screwed up the project and made it run late. And she’s usually good at
getting home on time. And she’s called me twice to apologize and
explain. Blaming and yelling just pulls me away from the partner I want
to be. So I’m going to use this as an opportunity to practice my new
skills. I’m going to drop anchor and practice the Kind Hands exercise.
There are similarities here to the CBT strategy of cognitive
reappraisal; the big differences are that there’s (a) no disputation of
cognitions and (b) no attempt to escape, avoid, or control emotions. We
defuse from unhelpful cognitions, accept the emotions, and take a new
perspective on the situation to enable effective values-guided action.
(And that’s why I’ve called this “reinterpreting” rather than
“reappraising”—to reduce confusion. In ACT terminology, this comes
under the umbrella of “flexible perspective taking.”)
The basic steps of this strategy are:

1. Drop anchor, unhook from your thoughts, make room for your
feelings.
2. Consider: What values do I want to bring into play? What
outcomes do I want to aim for?
3. Consider: How can I look at this in a different way that helps me
to act effectively?

(Keep in mind, we don’t necessarily need to follow this order; steps

2 and 3 are interchangeable. And if clients are not struggling with
cognitions and emotions, they can skip step 1.)

MOTIVATIONAL SELF-TALK
It’s often useful to have clients prepare in advance some
motivational prompts: short catchphrases they can use to nudge
themselves into action, keep them going, or foster their willingness. Here
are some examples:

This is hard, but it’s important.

Every step counts.
Rome wasn’t built in a day.
Just make a start; once you’re over the speed bump, it gets easier.
I don’t have to do it perfectly. It’s okay to make mistakes.
Little by little does the trick.
I can do this—even though it’s uncomfortable.
I don’t want to do this, but I’m willing to.
 I don’t have to do this; I choose to.
Here’s an opportunity to live my values.
Thinking about it won’t get it done.

I’m sure you can think of many others. Indeed, there are many
famous quotes and sayings we can recruit for this purpose. For example,
when I’m finding it hard to keep writing because my mind says it’s
rubbish, I remind myself of Ernest Hemingway’s quote: “The first draft
of anything is shit!” At other times, when my mind beats me up for not
writing fast enough, I remind myself of Aesop’s saying: “Slow and
steady wins the race.” Usually this self-talk keeps me going. The key
ways to keep motivational self-talk ACT-congruent are to (a) make it
realistic, (b) not try using it to avoid or get rid of unwanted thoughts and
feelings, and (c) ensure it’s aligned with values.

“I Just Don’t Know How to Do It!”

Sometimes clients will identify a value but then fuse with I don’t
know how to do this! For example, clients who tend to self-sacrifice,
people-please, or be overly responsible for others may want to take
better care of themselves but have little or no idea of what this looks like
behaviorally. To help them with this, we may:

suggest they watch movies and TV shows, or read books, and (a)
look for actions of self-care the characters take, and then (b)
consider how to translate that to their own life;
teach them assertiveness skills, including basic psychoeducation
about their rights and the rights of others, how to say no, and how to
set boundaries;
suggest they google “self-care activities” to find a huge number of
suggestions;
ask them to complete activity-monitoring worksheets, rating each
activity on a self-care scale of zero to ten (ten = very caring for self,
zero = not at all caring for self); and
 ask them to imagine a role reversal: “If you were caring for
someone else, what would that look like/sound like? Now how can
you do something similar for yourself?”

In addition, such clients will need good acceptance skills, because

self-care will trigger much anxiety, and defusion skills, to unhook from
rules like “I must put others first” and “I am unworthy.” Although the
example above is for self-care, these basic strategies can be modified and
adapted for any value a client does not know how to operationalize.

Is Attention Training Needed?

You may recall that in chapter eight we touched on the importance
of attention training as an antidote to distractibility and disengagement.
If clients find it hard to focus on or engage in a new values-based
activity, they probably won’t find it very satisfying; and if it’s a complex
task, they probably won’t do it well. In such cases, we can introduce (or
revisit) attention-training practices (e.g., traditional mindfulness of the
breath) and encourage clients to practice them regularly. The idea is to
develop their focusing skills and apply them to these new activities.

Setbacks Happen
Committed action is a bumpy road. As our clients expand their lives
through acting on their values, they will have successes and failures,
breakthroughs and setbacks. At times things will go better than they ever
expected; at other times they will go horribly wrong.
When setbacks happen, the first step is to acknowledge how painful
that is, make room for the feelings, and practice self-compassion. This
includes both defusion from harsh judgments (That was a total waste of
time, This shows how useless I am) and compassionate self-talk (At least
I tried, Everybody has setbacks, Tomorrow is another day).
The second step is reflection: Even though overall it did not go
well, were there any moments—no matter how brief—where things did
go well, or I had a sense of being more like the person I want to be? Is
there anything I can learn from this? What worked? What didn’t work?
What could I do more of, less of, or differently next time around?
This reflective practice not only reframes setbacks as learning
opportunities, but also acts as an antidote to the harsh judgments
mentioned above. It also often suggests new homework activities.

EXTRA BIT In Trauma-Focused ACT: The Extra Bits, chapter

sixteen, you’ll find worksheets for setting SMART goals, values-
based problem solving, overcoming HARD barriers, monitoring,
and scheduling activities.

Takeaway
When translating values into actions, we help our clients set goals, create
action plans, solve problems, and learn skills; we facilitate flexible
contact with important aspects of life the client has been avoiding
(technically, this is exposure); and we encourage experimentation with
new behaviors. We continually check that clients are genuinely willing
and their goals are realistic. We can expect the HARD barriers—Hooked,
Avoiding discomfort, Remoteness from values, and Doubtful goals—to
arise repeatedly; and to help clients get past these, we use defusion,
acceptance, connection with values, and SMART goal setting.
 CHAPTER SEVENTEEN.

Undermining Problematic
Behavior

How do we do TFACT with substance abuse, suicidality, social

withdrawal, self-harming, aggression, gambling, reckless risk taking,
self-neglect, self-harm, hygiene, lying, stealing, compulsive checking or
cleaning, fawning, excessive bed rest, procrastination…or just about any
other problematic behavior you can think of? I’m so glad you asked! In
this chapter, we’ll explore a four-step approach to undermining any type
of problematic, destructive, or self-defeating behavior. Once you have a
handle on this, you can figure out how to use TFACT with almost
anything.

Function Matters!
Before we get into the four steps, I want to introduce (or renew your
acquaintance with) the concept that underpins them: “functional
analysis.” This means figuring out the “functions” of a behavior: the
effects it has, or what it achieves, in a particular situation. When we
focus on any problematic behavior, functional analysis is the best place
to start because it opens many possibilities for specific, carefully targeted
interventions.
To figure out the functions of a behavior, we need to know (a) what
triggers it—the “antecedents,” and (b) what the immediate outcomes are
—the “consequences.” Antecedents can include situations, cognitions,
emotions, urges, sensations, memories; anything you can see, hear,
touch, taste, and smell; and physiological states, such as thirst, hunger,
illness, or fatigue. (On a choice point diagram, antecedents always go on
the bottom.) So basically, antecedents are anything present—in your
inner or outer world—that directly triggers (or, to use the technical term,
“cues”) the behavior in question.
If the immediate outcomes are such that the behavior continues or
increases, they are known as “reinforcing consequences,” or
“reinforcers”; they reinforce the behavior. Conversely, if the immediate
outcomes are such that the behavior discontinues or reduces, they are
known as “punishing consequences,” or “punishers”; they punish the
behavior.
Once we know the antecedents and consequences for any given
behavior, we know its functions: the effects it has, or what it achieves, in
this situation. For example, suppose that a client, alone in their apartment
at night, has intense feelings of anxiety (antecedents) that trigger the
overt behavior of smoking marijuana. They smoke a joint, and the
immediate outcomes are (a) their anxiety disappears, and (b) they feel
calm and relaxed. These outcomes keep the habit going—so they are
reinforcing consequences. We now know at least two functions of
smoking marijuana in this particular situation: to avoid anxiety and to
feel relaxed. The diagram below shows how we could plot this out on a
choice point; in this case, the client sees smoking marijuana as a “bad
habit” that they want to kick, so it goes on the away arrow. (If desired,
you can write the reinforcing consequences in a “payoffs” box, as
illustrated.)
 Now let’s consider the functions of smoking marijuana for a
different person in a different situation. This client is a sixteen-year-old
at a party. As he sees his friends taking turns smoking a joint, he
experiences feelings of excitement, a pleasurable sense of risk taking and
adventure, and the desire to join in. These thoughts and feelings are the
antecedents for what he does next: smokes the joint. The immediate
outcomes are an enjoyable feeling of doing something cool and
adventurous and a sense of camaraderie and belonging to the group.
These outcomes make it more likely that he will do the same thing in
similar situations in the future—so they are reinforcing consequences.
Therefore, the main functions of this behavior are fitting in with his
social group and the excitement of risk taking.
In the choice point diagram below, the client sees this behavior as
something he wants to keep doing, in line with his values of social
connection, having fun, and being adventurous—so it goes on the
towards arrow.
 Both examples above analyze what is reinforcing behavior. At other
times, if a desired behavior is reducing in frequency, we may analyze
what is punishing it. The figure below illustrates the choice point in
terms of antecedents, behaviors, and consequences.
Four Steps to Undermine Any
Problematic Behavior
When a client wants to reduce or stop a problematic behavior, we
typically go through a four-step process, answering the following
questions:

1. What triggers the behavior?

2. What are the costs and benefits?
3. What’s a good alternative?
4. What skills are needed?

Before we explore these four steps, a practical note: When we wish

to undermine any problematic behavior, we first need to specify what it
involves: what is the person actually saying and doing? Specifically,
what would we see them doing and hear them saying if we watched it on
a video recording? (Covert behaviors, such as worrying and ruminating,
can’t be seen or heard on a video, so instead we specify them as
“worrying about XYZ” or “ruminating about ABC.”)
So, for a behavior described as “taking drugs,” we want to know
what substances are taken, how, in what quantities, and with what
frequency? And for a behavior described as “social withdrawal”: does
that mean canceling social events at the last minute, staying home when
friends are out partying, refusing to answer phone calls, or staying in
one’s bedroom to avoid other people in the house?
Usually, some gentle questioning is necessary. For example, when
clients say they want to “stop procrastinating,” we ask, “What are you
putting off doing?” (e.g., are they avoiding completing a tax return, or
going to the gym, or having a difficult conversation?). Then we ask,
“What do you do instead? What would I see and hear if I watched a
video of you procrastinating?” (e.g., do they stare at a wall, go for a
walk, surf the net, play video games, read books, hang out with family,
stay in bed?). Once we have this information, instead of a vague,
nonspecific term like “procrastinating,” we can work with a specific
description of the behavior, such as “watching TV instead of going to the
gym.”

Question One: What Triggers the

Behavior?
Having specified the behavior, we want to know: what are the
antecedents? What situations, thoughts, and feelings typically trigger it?
Are there particular people, places, events, activities, cognitions,
memories, emotions, sensations, or physiological states that cue this
behavior? (If a behavior is triggered by many different situations,
thoughts, and feelings, we focus on the most common ones. And if the
triggers are predominantly private experiences, we may focus primarily
on the cognitions and emotions, rather than situations.)
If clients aren’t sure what triggers their behavior, one good option is
to suggest they keep a diary: write down when and where they do it, and
what they were feeling and thinking immediately beforehand. (There’s a
worksheet for this in Extra Bits.) Another option is to help the client
recall, as vividly as possible, the last time they did the behavior, then
“rewind” the memory to the moment immediately before they started
doing it and see if they can remember the thoughts and feelings present
at that moment.

Experiment on Yourself
A great way to learn the strategies in this chapter is to apply them
to yourself. If you’re willing to do this, pick an overt behavior you’d
like to reduce. (It’s easier to work with overt behaviors when
you’re new to this). You can use the “Functional Analysis
Worksheet” in Extra Bits, or a blank sheet of paper, and begin by
writing down a specific description of the behavior. Then, write
down the antecedents.
 Question Two: What Are the Costs
and Benefits?
Any type of behavior has both benefits and costs. It’s not essential
to identify the benefits, but it’s often helpful, because (a) it gives clients
insight into why they keep doing this, and (b) it helps to validate the
behavior, which facilitates self-compassion. Basically, the benefits of
any behavior boil down to either or both of the following:

You get to escape or avoid an “aversive stimulus” (i.e., something

you don’t want)
You get to approach or access an “appetitive stimulus” (i.e.,
something you do want)

Remember, when the benefits are such that the behavior continues
or increases, we call them reinforcing consequences. Below are some
common reinforcers for problematic behaviors.

The behavior helps us to:

escape or avoid challenging people, places, situations, or activities
escape or avoid unwanted cognitions, emotions, memories, or
sensations
get our needs met
gain attention
gain approval
get others to do what we want
“look good” to others
“fit in” with others
feel better (e.g., relaxed, calm, happy, safe)
feel righteous (we are “in the right,” and others are “wrong”)
feel like we are successfully following important rules
 feel like we are working hard on ourselves or our problems
feel like we are making sense (e.g., of life, the world, ourselves,
others)
feel comfortable by doing something familiar

There’s a truly vast number of possible reinforcers—but most of

them will fit under one or more of the broad categories above (usually
several). Useful questions to identify them include:
Any idea what’s keeping this behavior going?
Does it have any benefits you can identify?
Does it help you get something you want?
Does it help to save or protect you from something you don’t
want?
If clients can’t answer these questions, we have three options. One
option is to explore a bit more: “What usually happens—the moment
you start doing this? Is there a moment when you first start doing it when
there’s a sense of getting something you want or getting away from
something you don’t want?”
A second option is to show clients the list of common reinforcers
above (using the worksheet in Extra Bits).
And a third option is psychoeducation. For example: “There are
three big benefits to worrying: (a) it helps us prepare for bad things that
might happen; (b) it pulls us into our thoughts, which helps us to escape
from feelings in our body; and (c) it feels like we’re working hard on our
problems.”
Occasionally, despite our best efforts, we just can’t figure out
what’s reinforcing the behavior—and that’s okay. It’s useful, not
essential; we don’t have to know the benefits in order to change
behavior. It’s much more important to get clear on the costs of the
behavior.
When clients are contemplating changing their behavior, they are
already aware of some of the costs—otherwise, why change? And often,
they have already told us some of them. However, we now prompt them
to reflect more deeply (just as in creative hopelessness). For example:
Have you noticed any costs or drawbacks to this behavior? Any
unintended negative consequences?
Is there anything important that you lose or miss out on when you
do this?
Does it lead to anything in your life that you don’t really want?
Does it hold you back from anyone or anything important?
Does it take you away from any important values or goals?
And if we see some area of the client’s life that their behavior is
impacting negatively—but the client doesn’t yet see it—we prompt
them. We might say, for example, “I can’t help wondering: what effect
does this have on your relationship with your partner?”
After identifying costs, we give a compassionate and
nonjudgmental summary, looking at the behavior in terms of workability.
The basic script is as follows: “So it seems that DEF (antecedents) tend
to trigger G (specific behavior), which has some real benefits, such as
HIJ (reinforcing consequences), but also some significant costs, such as
KLM (adverse outcomes). For example:
Therapist: I’m going to have a go at summarizing this, and
please tell me if I don’t get it right. It seems like often in
the evenings, lots of anxious thoughts and feelings
show up for you, as well as these bad memories. And
when you get hooked by that stuff, you drink beer and
wine. And there’s a real short-term benefit: it reduces
your pain, helps you unwind, helps you forget. But in
the long term, it’s affecting your health and well-being.
You don’t sleep well, and you’re often hungover, which
affects your work performance. Your anxiety’s getting
worse, not better. Your wife is upset. Your kids are
upset. You’re missing out on the family life you want.
And you’re not being the sort of husband or father you
want to be.
 Experiment on Yourself
Okay, back to you again. What are the costs and benefits of your
own behavior that you selected in the previous exercise? Please
think about it carefully and identify as many as possible. Write
them down, then summarize the information gathered so far, as
exemplified above.

Question Three: What’s a Good

Alternative?
The third step is to consider what new, effective behavior the client
will do (instead of the old, problematic one). For example:

If you don’t yell at your kids when they bug you, what will you do
instead?
If you don’t stub cigarettes on your arms when these memories
resurface, what will you do instead?
If you don’t get drunk after you quarrel with your partner, what will
you do instead?

This brings us full circle to the previous two chapters: new,

effective behaviors, guided by values. For example, regarding the bullet
points above, the client may choose these new behaviors: (a) instead of
yelling, they may patiently make an assertive statement, or accept it’s
happened and make a joke out of it, or talk calmly and honestly about
their feelings; (b) instead of self-harming with cigarettes, they may
firmly massage their arms and forearms, or do some stretching, or
commence a self-soothing practice; or (c) instead of getting drunk, they
may just have one or two drinks, or do a self-compassion practice, or go
for a run around the block.
 Experiment on Yourself
Now back to you again. So if you don’t do what you normally do
when all that difficult stuff shows up, what will you do instead? Write
down a new, values-guided behavior, and consider:

What values does this serve?

What difficult thoughts and feelings go with it? Are you
willing to make room for them?
Is this at least a seven out of ten, in terms of how
realistic it is? If not, make it simpler and easier, until
you can score at least seven.

Question Four: What Skills

Are Needed?
We now need to identify what skills the client needs to respond
flexibly to (a) the antecedents to their old behavior, and (b) the HARD
barriers to their new behavior. For example, do they need skills in
defusion? Acceptance? Self-compassion? Urge surfing? Dropping
anchor? Connecting with values? If the client already has these skills, we
explore how to apply them. But if these skills are lacking, we help
clients develop them.

Experiment on Yourself
So, one last time, back to you: What skills do you need to handle
the antecedents to your problematic behavior and to overcome
the HARD barriers to your new, effective behavior? How will you
apply them?
EXTRA BIT In Trauma-Focused ACT: The Extra Bits
(downloadable from “Free Resources” on
http://www.ImLearningACT.com) in chapter seventeen, you’ll
find (a) a generic functional analysis worksheet, (b) a choice-
point-based functional analysis worksheet, and (c) an
undermining problematic behavior worksheet.

Takeaway
We covered four steps in this chapter for undermining problematic
behavior, involving the following four questions:

1. What triggers the behavior?

2. What are the costs and benefits?
3. What’s a good alternative?
4. What skills are needed?

These steps are guidelines, not commandments. We don’t always

have to cover all of them, and we can readily change the order as
desired. What I’m hoping and trusting is that you can now, using these
guidelines, figure out how to use TFACT with just about any
problematic behavior you encounter.
 CHAPTER EIGHTEEN.

Overcoming Barriers,
Maintaining Change

Are you currently putting off any important tasks? Are there things you
could be doing that you know full well will improve your life—but
you’re not doing them? Of course there are! Because you’re human. And
this is something we have in common with our clients. So when a client
reports that they haven’t done their homework, one good response is,
“You are so like me!” We then explain to the shocked client, “We all do
it. We all say, ‘Yes, I’m going to do X and Y and Z’—and then we don’t
do it. It’s normal.” We then check to see if the client is fusing with self-
judgment or struggling with shame or anxiety—and if so, we segue into
dropping anchor, defusion, acceptance, or self-compassion, as needed.
After this, we put this issue onto the agenda for the session. If the
client is reluctant to do this, we could say, “I know you want your life to
be better…you’ve mentioned things like (recaps some of the client’s
therapy goals)…and the only way to make that happen is to follow
through on this stuff, outside of our sessions. And the problem is,
whatever stopped you from following through last time is likely to stop
you again, this time and next time—unless we figure out how you can
overcome it. So can we just spend a few minutes to figure out what the
obstacle is, and come up with a strategy to overcome it?”

The Main Barriers to Committed Action

If clients aren’t following through on committed action between
sessions, we need to take a good look at…ourselves! Much of the time,
clients don’t follow through because therapists skip important steps, such
as specifying the behavior, linking it to values, checking for willingness,
anticipating obstacles, preparing a contingency plan, or ensuring a
realism score of at least seven.
We also need to consider: is the therapeutic alliance strong? If not,
we work on improving it.
Finally, we consider whether there are any HARD barriers. Is the
client Hooked, Avoiding discomfort, Remote from values, or pursuing
Doubtful goals? If so, we bring in the antidotes: unhooking; accepting
discomfort; connecting with values; and SMART goals.

Maintaining Change: The Seven Rs

It’s one thing to start some new type of life-enhancing behavior; it’s
another thing to keep it going. So how can we help our clients sustain
their new patterns of behavior? There are hundreds of tools out there to
help us with this challenge, but we can pretty much bundle them all into
“the seven Rs”: reminders, records, rewards, routines, relationships,
reflecting, and restructuring the environment.

Reminders
Clients can use all sorts of simple tools to help remind them of their
new behavior, for example, a pop-up or screensaver on their computer or
smartphone with a key word, phrase, or symbol. Or there’s the old
favorite of writing a message on a card and sticking it on the fridge or
bathroom mirror. This might be just one word, like “Breathe” or “Pause”
or “Patience,” or a phrase like “Letting go” or “Caring and
compassionate.” Alternatively, they could put a brightly colored sticker
on the strap of their wristwatch or their computer keyboard—so each
time they use these devices the sticker reminds them to do the new
behavior. And on top of all that, there are smartphone apps; for example,
the “ACT Companion” app will send you brief messages about different
aspects of ACT throughout the day. (These strategies are also good for
clients who keep “forgetting” to do their homework.)

Records
Clients can keep a record of their new behavior throughout the day,
writing down when and where they do it and what the benefits are. Any
diary or notebook—on paper or on a computer screen—can serve this
purpose. (Worksheets are handy, too.)

Rewards
Acting on one’s values is (usually) intrinsically rewarding—and
becomes even more so when we encourage clients to practice mindfully
appreciating the experience. However, additional rewards are helpful to
reinforce the new behavior. One form of reward is kind, encouraging
self-talk, such as saying to oneself, Well done. You did it! Another form
of reward is sharing success and progress with a loved one who is likely
to respond positively. Some clients might prefer more material rewards.
For example, if they sustain this new behavior for a whole week, they
get to buy or do something that they really like, such as get a massage or
buy a book.

Routines
We can explain to clients, “If you get up every morning at the same
time to exercise or do yoga, over time that regular routine will start to
come naturally. You won’t have to think so hard about doing it; it will
require less ‘willpower’; it will become a part of your regular routine.”
We can then encourage them to experiment: see if they can find some
way to build a regular routine or ritual around their new behavior so it
starts to become part of their everyday way of life. For example, if they
drive home from work, then every night, just before they get out of the
car, they might do two minutes of dropping anchor, and then consider
what values they want to bring into play when they go through the front
door into their home.

Relationships
It’s easier to study if you have a “study buddy”; easier to exercise if
you have an “exercise buddy.” So we can encourage clients to find a
kind, caring, encouraging person who can help support them with their
new behavior. (Sometimes the therapist is the only person who can play
this role.) Ideally clients check in with this person on a regular basis and
share their progress (as mentioned in “Rewards”) in person or via text or
email. Or they can use the other person as a “reminder.” For example, a
client might say to their partner, “When I raise my voice, can you please
remind me to drop anchor?”

Reflecting
We can encourage clients to regularly reflect on how they are
behaving and what effect it is having. They can do this via writing it
down (i.e., through records) or in discussion with another person (i.e.,
through relationships). Or they can do this as a mental exercise
throughout the day or just before bed. We might ask them to take a few
moments to reflect: How am I doing? What am I doing that’s working?
What am I doing that’s not working? What can I do more of, or less of,
or differently?

Restructuring the Environment

Clients can often restructure their environment to make their new
behavior easier. For example, if the new behavior involves healthy
eating, they can restructure the kitchen: get rid of or hide away the junk
food and stock the fridge and pantry with healthy stuff. If the new
behavior is drinking water and tea in the evenings, instead of beer or
wine—they can remove the alcohol. If they want to go to the gym in the
morning, they could pack up their sports gear in their gym bag and place
it beside the bed or somewhere else obvious and convenient, so it’s all
ready to go as soon as they get up. (And of course, when they see the
gym kit, it acts as a reminder.)
So, those are the seven Rs: reminders, records, rewards, routines,
relationships, reflecting, and restructuring the environment. The idea is
to be creative; help your clients mix and match these methods to create
their own strategies for lasting change.

EXTRA BIT In chapter eighteen of Trauma-Focused ACT: The

Extra Bits, you’ll find a client handout on the seven Rs.

Takeaway
If clients aren’t following through on homework or sustaining their new
behaviors, we want to make that a top priority for the session. We can
usually quickly identify the barriers and introduce useful tools to get past
them—especially the seven Rs.
 CHAPTER NINETEEN.

When Things Go Wrong

In 1887, British engineer Albert Holt, pioneer of the long-distance

steamship, reportedly wrote, “It is found that anything that can go wrong
at sea, generally does go wrong, sooner or later.” For some unknown
reason, this later became known as Murphy’s law: “Whatever can go
wrong, will go wrong.” (So there you go; don’t say you didn’t learn
anything in this book!)
Murphy’s law is just as relevant to therapy as to steamships; if you
can imagine something going awry in TFACT, the chances are, sooner or
later, it will. So this chapter is to help us prepare in advance. I’ve
chunked it into five sections: (1) backfired experiments—when
interventions fail or trigger adverse reactions; (2) session stoppers—
when clients behave in ways that disrupt or stall the session; (3)
teamwork troubles—interpersonal tensions between client and therapist;
(4) working on ourselves—overcoming our own fusion and avoidance in
session; and (5) preparing ourselves for a challenging session.

Backfired Experiments
Everything we do in therapy is an experiment; we never know for sure
what will happen. Even a simple question or innocuous comment can
sometimes trigger an extreme adverse reaction. So inevitably our
experiential work will sometimes fall flat, fail miserably, or have
unintended negative consequences.
 Three common reasons for backfiring experiments are:

The therapist does not establish ACT-congruent goals for therapy.

The therapist does not clearly link experiential work—especially
mindfulness and acceptance practices—to the client’s ACT-
congruent therapy goals.
The therapist encourages the client to talk about traumatic events
but relies on reflective listing and supportive counseling instead of
helping the client develop new skills for flexible responding.

Watch out for these mistakes (they’re easy to make when you’re
new to TFACT) and remedy them as soon as you realize they’ve
happened.
When things go awry in session, we want to model, instigate, and
reinforce TFACT processes as a response. This usually involves some or
all of the following:

drop anchor
explore and validate
thank the client
apologize
clarify
create a learning opportunity

Let’s quickly go through these.

Drop Anchor
We are in the same boat as our clients; when something goes wrong,
we experience all sorts of uncomfortable thoughts and feelings—
especially anxiety. So we drop anchor ourselves, and help our clients do
likewise. If the client is having a strong adverse reaction (e.g., fusion,
extremes of arousal, dissociation), we run through the ACE process, to
keep them within their window of flexibility. And as therapy progresses
and the client learns more skills—defusion, acceptance, self-compassion,
and so on—we bring those in too.

Explore and Validate

When things go askew, we ask about the client’s thoughts and
feelings, and we validate whatever is showing up. Then, with openness
and curiosity, we explore: “Clearly that didn’t go as intended. What
happened?” We want to discover: Did the client misunderstand the aim?
Did we go too fast or was the exercise too hard? Were they not truly
willing to do it? Did the exercise trigger painful inner experiences, such
as traumatic memories, intense emotions, or harsh self-judgments? Did
we say or do something dismissive, uncaring, or invalidating?
Or did the exercise simply have a different effect from what was
intended? For example, every defusion technique occasionally results in
fusion; every self-compassion technique occasionally triggers self-
judgment.

Thank the Client

When clients give us feedback that something went wrong, we
thank them for it—even if it’s harsh or abrasive (like “This is stupid!” or
“It’s not fucking working!”). We might say (and obviously we need to be
completely authentic and genuine), “Thank you for being honest with
me. I appreciate the feedback, because if something’s not working for
you, we need to sort that out, pronto.”

Apologize
If the experiment backfired due to some error or misjudgment on
our part, an apology is warranted. We might say, “I’m sorry. I can see
now, I didn’t clearly explain the purpose to you,” or, “I’m so sorry. I
wasn’t expecting that to happen,” or “I’m really sorry. I think I pushed
you into that before you were ready for it.” When we do this genuinely,
it models authenticity, openness, and taking responsibility—while also
repairing the breach.

Clarify
Is the issue one of misunderstanding? Maybe you didn’t clearly
explain the purpose of the exercise, or perhaps the client misunderstood
it (e.g., expecting it to get rid of unwanted feelings)–or both. If so, you
should calmly and openly explain what you had meant or intended. This
may involve revisiting metaphors such as Hand as Thoughts, Pushing
Away Paper, or, in the case of dropping anchor, a reminder that anchors
don’t control storms. In other cases, this may mean clarifying the use of
particular terms: “I’m sorry. When I used the term ‘story,’ I didn’t mean
it’s not true or you were making it up. It’s just a more user-friendly way
of talking, instead of using technical terms like ‘cognition.’ I certainly
won’t use that term again.”

Create a Learning Opportunity

Can the client learn something useful from this unexpected,
unwanted experience? The answer is usually yes—provided we foster
openness and curiosity. We may say, “Obviously neither of us wanted
this to happen, but given that it did, I’m wondering if there’s something
useful to learn from it.” Possible lessons may include how to use
defusion, acceptance, or self-compassion skills; how to respond flexibly
to difficult emotions; and how to accept it when things go wrong and
carry on doing what’s important.
We may not need to go through all the above responses—one or
two may be enough. What matters most is to stay present and respond
with openness, curiosity, and compassion. As part of these conversations
(and this also applies for session stoppers and teamwork troubles), we
always inquire about the client’s thoughts and feelings. We might say,
“These kinds of discussions are quite confronting for most people—so
I’m wondering, what’s showing up for you?” Often all that’s required is
to validate their reaction, but sometimes it’s necessary to bring in
defusion, acceptance, or dropping anchor.

Session Stoppers
From time to time, we all have clients who behave “problematically”
during the session. They may continually vent about their problems
without letting us get a word in; or blame all the people in their life
without ever looking at their own role in ongoing issues; or repeat the
same narratives week after week without any obvious purpose. They
may get bogged down in intellectualizing and “analysis paralysis.” They
may repeatedly talk over or interrupt us. They may keep “problem
hopping”—moving rapidly from one issue to another, never sticking
with one long enough to generate an action plan.
And let’s be honest: haven’t we all at times simply gritted our teeth
and tried to put up with this behavior, and “get through the session”—
rather than openly addressing it with the client? Usually, we do this
because we get hooked by our own anxiety and reason-giving: It would
be rude of me to interrupt, They’ll get upset if I mention it, It’s good for
them to vent, Maybe they just need to do this.
“Press pause” (chapter four) is often a good intervention here: “Can
I press pause for a moment? I’m noticing something happening here, and
I’d really like to bring it to your attention. My mind’s telling me you’re
going to be upset or offended by what I say, and I’m noticing a lot of
anxiety in my body, and a strong urge just to sit here and not say
anything about it. However, I’m committed to helping you create the
best life you can possibly have. So, if I sit here and say nothing about
this, then I don’t think I’m doing my job properly; I don’t think I’m
being true to you, as a therapist. So, I’m going to do what matters here,
even though my heart is racing—I’m going to tell you what I’m
noticing.”
 Notice how, in doing this, we model five of the six core processes:
contact with the present moment, defusion, acceptance, values, and
committed action. And by now, we’ll have our client’s full attention!
Here’s a shorter version: “Can I press pause for a moment? I’m
wanting to talk about something that I think is going on, and my mind’s
telling me that I’m going to come across as rude or insensitive…
however, I don’t want to let my mind talk me out of it because I think it’s
really important…so, is it okay with you if I share what I think may be
happening here?”
Then, with an attitude of openness and curiosity (unhooking
ourselves from any judgments), we can compassionately and respectfully
bring in the notice, name, normalize, purpose, workability strategies.
When noticing and naming behavior, it’s essential that our description is
nonjudgmental. For example, we would not say, “You’re being
aggressive”—because that’s a judgment about the behavior, and the
client may take offense or argue that they’re “not being aggressive.” In
contrast, here’s a nonjudgmental description: “I notice that your voice is
getting louder, and you’ve clenched your fists, and you’re frowning.”
Following this, we can normalize the behavior, consider its purpose,
and look at it in terms of workability. Here’s an example, for a client
who keeps problem hopping:
Therapist: (noticing and naming) What I’ve noticed is this
pattern—we start talking about a problem or topic,
but before we get a chance to come up with an
effective strategy, you move on to another issue.
Have you noticed this yourself?
Client: Yes. That’s because I’ve got so many problems to
deal with!
Therapist: (normalizing) Absolutely. And it’s completely
normal. My mind does it too. When we’ve got a lot
of problems, our minds naturally jump from one to
another. (exploring the purpose) This is your mind
looking out for you; it’s saying, “Look—you have to
 deal with all of this stuff. You can’t neglect any of it.
You have to cover all bases.”
Client: Yeah. It’s always doing that.
Therapist: (workability) The thing is, if we let your mind
keep doing that in our sessions, you’re not going
to get much out of therapy. If we want to make
these sessions effective, so that you can…
(mentions several of the client’s goals)…then we
need to stay on task, focus on one problem long
enough to come up with a plan or a strategy or
something practical to do.
It’s often nerve-racking to have these conversations with clients, but
it fosters authentic, courageous therapeutic interactions. (And if at any
point, the client reacts negatively—aggression, shutting down, crying,
and so forth—we respond as we would for “backfired experiments.”)
The next step is for client and therapist to collaborate on catching
and interrupting the problematic behavior when it recurs. For example,
we may make an agreement that either party can “call out” the behavior
when it happens—and both parties will then pause for a few seconds.
Continuing with the example of problem hopping:
Therapist: So how about we try this: we agree to focus on
one issue at a time, and stay with it for as long as
necessary to come up with a strategy—something
practical, that we can write down, so you can take
it home and do it. And then, if there’s time, we can
move on to another issue. Would that be okay?
And if at any point your mind tries to pull us off-
task, switch over to some other issue, then either
one of us can call it out. Can you think of a phrase
we could use to name it when we see it?
Client: Errmm, not really.
Therapist: How about we just say “switching”—to indicate
your mind’s trying to switch problems?
 Client: You’re going to say it? Or I am?
Therapist: Either. I expect, to begin with, it’ll be mostly me,
but after a while, you’ll start to catch your mind in
the act, and call it out yourself. So basically, as
soon as one of us notices what’s happening, we
say “switching.” Then we pause for a few seconds
—maybe take a slow breath or have a stretch—
and then we refocus on the original problem.
This strategy provides an ongoing means of raising awareness of a
problematic behavior, while also developing the client’s ability to (a)
interrupt it and (b) refocus attention on the task at hand. And of course,
we don’t need to stick to the agreed-upon phrase; we can use more
playful comments, such as “There it goes again” or “Did you spot it?”
As therapy progresses, we phase out this strategy and instead
simply ask, “And what do you notice going on right now?” or “What do
you notice happening here?” We may then explore: “Where is this
leading?” or “If we continue down this path, will that be a good use of
our time?” or “Is this helping us work together as a team?”
Here’s another example:
Therapist: (noticing and naming) What I’ve noticed is,
sometimes I’m talking and you interrupt and talk
over me. Have you noticed this yourself?
Client: (surprised) No, I haven’t. I talk the same way to you I
talk to everyone else.
Therapist: (normalizing) Well, of course, we all interrupt and
talk over each other at times. (exploring the
purpose) And I’m guessing you do this because
there’s a lot you want to talk about, and you want
to make sure we don’t miss anything.
Client: That’s right. So, what the problem? Isn’t that what
therapy is about? Talking about shit? No one’s
ever had a problem with this before.
 Therapist: (workability) Well, the thing is, in order for us to
be an effective team, we need to treat each other
with care and respect, and that means—
Client: Are you saying I don’t respect you?
Therapist: Do you notice how you just talked over me
again? Each time you do that, for me, it feels a bit
like a slap in the face. The message you send me
when you do that is that what I have to say isn’t
important, isn’t worth listening to. And that’s quite
hurtful; it gets in the way of us building a strong
team.
Client: Oh. (goes quiet, looks thoughtful)
Therapist: And I really appreciate what you’re doing right
now. Instead of talking over me—you’re listening.
And that feels so different to me; so much more
caring and respectful.
Client: (uncertainly) Okay.
Therapist: And again, I really appreciate you letting me talk
—this is a really uncomfortable conversation—and
it means a lot to me that you aren’t talking over
me. I already feel we’re a stronger team because
of it. So could we make that one of our tasks here?
To spot patterns of behavior that get in the way of
good, effective teamwork—and press pause when
they happen, and try something different?
Many clients have problematic patterns of interpersonal behavior,
which show up in their relationship with the practitioner. After raising
awareness of such behavior, as above, we can explicitly draw out its
relevance to therapy goals such as building better relationships. We
openly discuss the effect it has on the therapeutic alliance, then explore if
it shows up in other relationships—and if so, what impact it has. We then
get an agreement to catch it happening in session, press pause, then try
something more workable. For example, we might invite the client above
to experiment with active listening: paying curious attention to the
speaker’s face, mouth, and voice, and noticing the urge to interrupt
without acting on it.

Teamwork Troubles
Sigmund Freud talked about “transference” and “counter-transference.” I
prefer the simpler term, “teamwork troubles”: patterns of behavior that
undermine the therapeutic alliance. (Not sure Siggy would approve of
that term, but hey—each to their own.) When teamwork troubles arise,
we first take a good, honest look at ourselves: What am I saying or doing
that might be causing or exacerbating this tension? For example, have
we been arrogant, dismissive, uncaring, pushy, argumentative,
patronizing—or even overly zealous about ACT? (I’ve been guilty of all
of these things at times!)
On the client’s side, contributing behaviors may include trying hard
to please you and agreeing with everything you say; debating,
challenging, or contradicting everything you say; calling you names or
disparaging your profession; using racist, sexist, or homophobic
language; turning up late to sessions or repeatedly canceling at the last
minute; excessively delaying payment; and so on.

Raising and Discussing Teamwork

Troubles
We raise and discuss teamwork troubles just as for session stoppers
(and if there are negative reactions, respond as for backfired
experiments). We may say, “Not sure if you remember, back on our first
session, I said the aim here is for you and me to work together as a team.
The thing is—and I’m curious to know if it’s the same for you—I don’t
feel like we’re a strong team, and I wonder if we can talk about what’s
getting in the way of that, and how we can make it better?”
 We then have an open and honest discussion, taking the greatest
care to be respectful and understanding, while also being assertive.
Judicious use of self-disclosure is helpful:

When you use terms like “bitches” to refer to women, I feel really
uncomfortable.
When you say things like “You don’t really care about me,” I feel a
bit hurt—because even if you don’t believe it, I really do care, and I
want our work here to be useful, to help you build a better life, and
I’ll be sad if that doesn’t happen.
When you keep saying, “This is all bullshit,” I feel anxious; my
mind says I’m not doing my job properly.
When you don’t pay your bills, I feel a bit resentful, and also a bit
embarrassed, because I don’t really want to hassle you about it.

We listen to the client’s perspective, validating their feelings—then,

as for session stoppers, agree to collaborate on catching and interrupting
the problematic behavior if it recurs.

How Are We Contributing to

Teamwork Troubles?
As mentioned above, we always want to look at our own role in
teamwork troubles—and be willing to apologize. We can ask, “I’ve been
thinking about my part in this—and I’m wondering, is there anything
I’ve been saying or doing that is not landing well with you?”
If clients are not forthcoming, we may prompt: “I’ve been
wondering if maybe I’ve been too XYZ—or perhaps too ABC?” If the
client confirms our suspicion, we might say, “I sincerely apologize for
that. I can imagine how unpleasant that was for you. And I’ll take a
different tack from now on. And if I ever slip back into that, please let
me know straight away.”
 What Can We Learn from Teamwork
Troubles?
When a client’s behavior strains the therapeutic relationship, there’s
a great opportunity to learn from it—because usually it’s creating
problems in other relationships, too. We can often fruitfully explore:
A. What is the client hoping will happen when they say or do these
things?
B. Is it having the effects the client hoped for? What effect is it
having on the therapeutic relationship?
C. What’s the past history of the behavior? How old is it? Did it
originate as a response to trauma or adversity? Did it serve some
useful purpose in past relationships—to help protect the client or
get their needs met?
D. Does it happen in other relationships today? What effect does it
have there?
The information we gather from these explorations is often
extremely helpful for working with relationship issues (chapter twenty-
eight).

Working on Ourselves
The therapeutic relationship is of central importance in TFACT. We aim
to see each client as a rainbow: a unique work of nature unfolding in
front of us; a privileged encounter we can savor and appreciate. We don’t
look at a rainbow and say, “Oh, how disappointing—if only that shade of
indigo were a bit deeper.” We admire the rainbow; and no matter how
faint it may be, we feel privileged to witness it. And we aim to bring this
same attitude to therapy: living our values; unhooking from judgments;
paying attention with openness, curiosity, and compassion. (This
metaphor is my homage to Carl Rogers, who famously said: “People are
just as wonderful as sunsets if you let them be. When I look at a sunset, I
don’t find myself saying, ‘Soften the orange a bit on the righthand
corner.’ I don’t try to control a sunset. I watch with awe as it unfolds.”)
When the alliance is strong, the client is motivated, and the session
is going smoothly, it’s easy to see a client as a rainbow. But it’s not so
easy when the client is deeply stuck: fused, avoidant, and responding
negatively to our interventions. Usually when this happens, that
“judgment factory” in our head goes into overdrive.
I’ve asked thousands of therapists to share judgmental thoughts
they have about their clients during difficult sessions. Here are some
common ones: She doesn’t really want to get better, I don’t like him,
She’s a hopeless case, This guy’s an asshole, She’s not really trying,
What on earth am I going to do with him? She’s clearly borderline, He
must be a narcissist, I wish she’d shut up, Oh no—here we go again,
This is infuriating, I can’t wait for this session to be over, How do I get
him out of here? I should refer her on to someone else, This is a waste of
time, Why do you keep coming back when we aren’t getting anywhere?
Will you shut up and let me get a word in? Can’t you see it’s your own
fault? Why do you keep doing this?
We’ve all had thoughts like this at times. We don’t consciously
choose them; they just “show up”—especially when the going gets
tough. And having such thoughts is not a problem; it’s normal, natural,
and expected. But if we fuse with those thoughts: big problem! The
client’s not a rainbow, but a roadblock! We see them as an obstacle—
getting in our way, holding us back; a problem we need to solve.
Naturally, this does not bode well for the session.
I’ve also asked thousands of therapists to share what away moves
they make when hooked by their thoughts and feelings in a difficult
session. Here are some common answers: I just nod my head and listen
and wait for the session to end, I become directive and pushy and tell the
client what they need to do, I open up my toolkit and start frantically
searching for tools and techniques, I end the session early, I suggest they
see another therapist, I talk louder and faster, I become pushy and
controlling, I disconnect and zone out, I give up on therapy and we just
chat, I get defensive, I start trotting out metaphors, I become snappy or
impatient.
 In other words, where there’s a stuck client, we tend to find a stuck
therapist. And thus the need to apply ACT to ourselves: to unhook from
unhelpful cognitions, make room for our emotions, connect with our
values, and be fully present with our clients. The good news is, the more
we use ACT on ourselves, the better we’ll be able to do it with our
clients—so let’s make a start on this, right now.

A Self-Development Exercise
Your mission, should you choose to accept it, is to identify your own
away moves in therapy sessions, and map out a plan for working on
them. I encourage you to write this out in the “Practitioner’s Barriers
Worksheet” (see Extra Bits). But if you are unwilling to write, then at
least think very carefully about it. (It’s so much more powerful if you
write it, though; just saying.) You can do this either as a broad-focus
exercise (i.e., covering a wide range of thoughts, feelings, and
behaviors that occur with many different clients) or as a narrow-focus
exercise, specific to just one client.

What Hooks You?

Write down client behaviors you find most difficult. And underneath
that, write down all the difficult thoughts and feelings that show up for
you in response. This may include difficult emotions (frustration,
anxiety, guilt, boredom, hopelessness); judgmental thoughts about
the client (such as those above); judgmental thoughts about yourself
(I’m a lousy therapist, I can’t do this) or the model (TFACT doesn’t
work!). Perhaps you also get hooked by perfectionism or other rigid
rules: I have to do this right, I mustn’t get this wrong, I’m not
experienced enough to do this, I can’t admit that I don’t know the
answer, or by reason-giving: I can’t do this experiential work
because it will upset the client, I’m too anxious to do this exercise.

What Are Your Away Moves?

Now write down what kind of values-incongruent, ineffective
behaviors you do when fusing with or avoiding those thoughts and
feelings.

What Are Your Towards Moves?

Write down several of your most important values as a practitioner
(e.g., compassion, respect, authenticity). To help you with this,
consider the following two questions:

1. Suppose I interview one of your clients and ask them, “What

are your therapist’s greatest qualities?” What would you like
your client to reply?
2. Next, I ask them, “When you were at your rock-bottom worst,
really struggling—how did your therapist treat you?” What
would you like your client to reply?

Next write down towards moves that you already do in response

to all those difficult thoughts and feelings that show up when you’re
challenged by your client’s behavior.
And finally, write down towards moves that you’d like to start
doing. This includes any unhooking skills you want to apply: tools,
techniques, practices, or exercises; any combination of defusion,
acceptance, contact with the present moment, self-compassion, and
self-as-context.
After completing it, please keep the “Practitioner’s Barriers
Worksheet” handy. The idea is for you to revisit this regularly and
use it as a guide for ongoing work on yourself.

Preparing Ourselves for a Challenging

Session
 The following exercise takes only two minutes. It’s especially useful
immediately before a session with a client whose behavior you find
difficult. So if you see a name in your appointment book, and you have a
sinking feeling, or anxiety, or a thought like I hope they cancel—please
do this before that session begins.

Compassion for Your Client

Take a moment to think of your client.
Consider: What does this client say or do in session that you
find challenging? What difficult thoughts and feelings show
up, in response?
Acknowledge: It’s hard for you to work with this client. It’s
painful. It’s difficult. It’s stressful. So acknowledge it’s hard,
and be kind to yourself.
Consider: This client’s “difficult” behavior results from fusion or
avoidance. They are not intending to make your life hard.
They are very deeply stuck. What might it be like for them to
live that way? To be so stuck? To be jerked around by their
thoughts and feelings, as if they are a puppet on a string? To
be pulled into problematic patterns of behavior, over and over
again, hurting and suffering as a result?
Consider: You only see this client for a short period of time,
with days or weeks in between sessions. Yet even in that brief
time, it’s challenging for you. So what’s likely to be happening
in your client’s other relationships—with friends, family, or
coworkers? How much tension, conflict, or disconnection is
likely? How painful must that be?

Can you put this client’s behavior to one side, and see the stuck,
struggling human being behind it? This person, just like you, wants
to love and be loved; to care and be cared for; to know and be
known. And right now, it’s hard for them to do that. But you can help.
You can make this relationship different from many others. You can
make it a secure and healing relationship, where your client’s difficult
behavior meets caring, understanding, and compassion. Don’t
underestimate the value of this; it is a great gift.
So take a moment to again think of your client—and truly
acknowledge their struggles and their suffering. And at the same
time, connect with your heart, and tap into your deepest reserves of
warmth and kindness and caring. Then, holding on to your
compassion, with your heart warm and open, go out and meet your
client.

EXTRA BIT Download Trauma-Focused ACT: The Extra Bits

from “Free Resources” on http://www.ImLearningACT.com. In
chapter nineteen, you’ll find the “Practitioner’s Barriers
Worksheet” and an MP3 audio file of the Compassion for Your
Client exercise.

Takeaway
We can’t stop judgments from arising when clients behave in ways we
find difficult, but we can defuse from our judgments, come back to our
values, tune into our compassion, and engage with our clients mindfully.
And when things go wrong, we can take a courageous, open, authentic
stance—and speak about it honestly. Often, we avoid such conversations
because we feel anxious or awkward—so we need to apply ACT to
ourselves: are we willing to make room for our own discomfort, in order
to live our values as practitioners?
 CHAPTER TWENTY.

Compassionate, Flexible
Exposure

A quick reminder: ACT defines exposure as “organized contact with

repertoire-narrowing stimuli, to facilitate response flexibility.” (Or, in
layman’s terms: “getting in touch with difficult stuff, to learn more
effective ways of responding to it.”) And no matter what exposure
involves—whether it’s increasing physical intimacy, connecting with the
body, or working with traumatic memories—one thing’s for sure: it’s
uncomfortable. It gives rise to all manner of difficult cognitions,
emotions, and sensations. So why on earth would anyone want to do it?

Values-Based Exposure
As discussed in chapter thirteen, exposure in TFACT is always in the
service of values and values-based goals—and the motivation needs to
be clear to both client and practitioner. What values and values-
congruent goals is this serving? What will this enable the client to do
differently?
The choice point diagram below illustrates the aims of TFACT-style
exposure:
 We can explain the aims of exposure to clients as follows: “The
idea of doing this exercise/learning this skill is so that next time you
encounter this stuff (mention repertoire-narrowing stimuli) you can
unhook from it/handle it better/respond more effectively—so that instead
of doing (mention away moves triggered by the stimuli), you can do
(mention values and values-congruent goals).”
Before, during, and after exposure, we repeatedly return to this
motivation. We say things like “Let’s take a moment to reconnect with
what this is all about…” Then we mention the client’s values-congruent
goals, such as being a loving mother, getting back to work, regaining
your independence, being there for your partner, gaining that promotion,
being more courageous, and so on. (With some clients, we may initially
do exposure in the service of vague values-oriented goals like “self-care”
or “building a better life,” but as therapy progresses, we want to get
much more specific.)

What Do We Measure?
Because the primary aim of exposure in TFACT is not to reduce
distress or anxiety but to increase emotional, cognitive, and behavioral
flexibility, there’s no need to measure the client’s distress using the
SUDS (Subjective Units of Distress Scale). Instead, we can use the three
scales we introduced earlier—presence, control over physical actions
(CPA), and willingness. A quick refresher:
 PRESENCE SCALE
On a scale of zero to ten, where ten means you’re fully present here
with me—engaged and focused and really tuned in to what we’re doing
—and zero means you’ve completely drifted off, gone off somewhere in
your head, lost all track of what we’re doing, then zero to ten, how
present are you right now?

CONTROL OF PHYSICAL ACTIONS

(CPA) SCALE
On a scale of zero to ten, where ten means you’ve got full control
over your physical actions—what you do with your arms and legs, hands
and feet—and zero means you’re completely frozen, locked up, can’t
move at all, then zero to ten, how much control do you have over your
actions right now?

WILLINGNESS SCALE
On a scale of zero to ten, where ten means you’re completely
willing to have these difficult thoughts and feelings—to let them be here
without trying to fight them or escape them—and zero means you’re
completely unwilling, you’ll do anything possible to make them go
away, then zero to ten, how willing are you to have them right now?

How Long Do Exercises Last?

Exposure activities may last for as long as the client is willing to
continue. But if at any point the client can no longer sustain a high level
of willingness, we immediately stop. (If we continue, this will just turn
into yet another occasion of fusion or experiential avoidance.)
Most of the exposure exercises in this book vary from ten to thirty
minutes, and I’ve provided approximate timings for quite a few of them.
However, they may be much shorter. Often we decide with the client
beforehand how long the practice will last. For example, if a client is
very hesitant, we may agree initially to just one minute. After that
minute is up and we’ve debriefed the exercise, if the client is willing, we
may encourage them to try again for perhaps two or three minutes. And
if they’re still willing after that, the third time we may go for four or five
minutes.
However, if we’re doing a longer exposure exercise, we may not
need to continue for the full agreed-upon time; if we reach a point where
the client is scoring high on all three scales, the task has been
accomplished, and we can stop.

Exposure and Response Flexibility

In TFACT we emphasize “exposure and response flexibility.” We want
clients to recognize that they have choices; that there are many ways of
responding to these stimuli. So we don’t tell clients what they can’t do;
rather we encourage them to choose more flexible responses in
preference to their older, more inflexible ones.
This especially applies to “safety behaviors”: overt or covert
behaviors that clients do during exposure to escape or avoid anxiety or
distress. For example, clients may try to distract themselves during
exposure by counting or thinking about something else; or they may
deliberately slow and deepen their breathing in order to relax. We watch
carefully for safety behaviors—and if they occur, make the client aware
of them. We gently point out it’s interfering with their learning, and
encourage them to refocus on the target stimuli.
Please keep in mind the following strategies to help clients build
response flexibility during exposure.

Keeping It Safe
All the safety strategies discussed in chapter four are important,
especially (a) a nonverbal gesture the client can use to ask for “time out,”
and (b) regular check-ins from the therapist to ensure the client is
genuinely willing (as opposed to “toughing it out” or trying to please the
therapist). And of course, we always aim to keep the client within their
window of flexibility, so if at any point they seem overwhelmed or
dissociative, drop anchor.

Move with the TIMES

TIMES is an acronym for Thoughts, Images, Memories, Emotions,
and Sensations. During exposure, all sorts of difficult private experiences
show up, and we can flexibly shift focus from one to another, as
required: we “move with the TIMES.”
For example, suppose we are working with a traumatic memory and
the client gets hooked by self-judgment. We then shift focus to defuse
from those self-judgmental cognitions. (If desired, we can track this with
the zero to ten defusion scale discussed in chapter ten.)
Once the client has defused from these thoughts, we refocus on the
memory. Now suppose a minute later, the client starts to dissociate; in
that case, we help them drop anchor—and we track their level of
presence and CPA. After the client is centered, we return to the memory.
And suppose shortly afterward, a huge wave of sadness shows up.
We then segue into acceptance and self-compassion, and track the level
of willingness. And once the client is accepting the sadness, we return to
the memory.
The diagram below illustrates this process. At any point, we can
help the client respond to any experience inside the triangle, using any
process on the outside—and we can freely shift from one private
experience to another: “moving with the TIMES.” (In Extra Bits, you
can find a copy of this diagram and an exposure record sheet.)
 Move with the TIMES

“Difficult TIMES”
We can help clients get in touch with “difficult TIMES” through
any of the methods explored in chapter thirteen: vividly remembering
something painful, imagining a difficult future event, setting challenging
goals, evoking urges, doing an avoided task, or working with
anticipatory anxiety. Here are three additional methods:

CREATE UNPLEASANT SENSATIONS

Often clients’ anxiety is triggered by unpleasant physical sensations
—such as dizziness, shortness of breath, or choking. With a bit of
creativity, we can help clients to recreate these sensations in session. For
example, we can ask a client to hyperventilate: to breathe extremely fast,
taking about two seconds for each full breath in and out. This usually
gives rise to sensations such as dizziness or light-headedness, a tight
chest, and pins and needles in the fingers.
Another method involves breathing through a narrow straw with
one’s nostrils pinched shut, for thirty to sixty seconds; this usually
creates a feeling of shortness of breath or suffocation. A third involves
swallowing repeatedly for one minute while really noticing the
sensations, which usually creates choking sensations.
These inductions usually continue for about one minute after the
first unpleasant sensations arise. (Exposure to physical sensations is
technically called “interoceptive exposure.”)

IMAGINE YOUR GREATEST FEARS

We can ask clients to vividly imagine what they fear (technically
called “imaginal exposure”). In PTSD, this is likely to be the
reoccurrence of something resembling the original trauma. However, as
we discussed earlier, traumatic events may give rise to the full range of
anxiety disorders, each of which have their own characteristic fears. For
example, in panic disorder there are typically fears of going crazy, losing
control, or having a heart attack; in social anxiety disorder, fears of being
ridiculed, embarrassed, or rejected; in OCD, fears of doing something
aggressive, lewd, or sacrilegious. So we can encourage clients to vividly
imagine the events they fear most.

IN VIVO EXPOSURE
In vivo (Latin for “in life”) exposure involves contacting a feared
situation, activity, or object in real life. With the advent of telehealth, in
vivo exposure has become much easier than before. For example, one of
my clients was mugged while withdrawing cash from an ATM
(automated teller machine) outside a bank—and had since avoided all
banks and ATMs, as they triggered high anxiety. In one of our sessions, I
was in the office, and he was in another location on his cell phone, and
during the session I coached him through first approaching and then
entering the bank, all the while defusing from and accepting his anxiety.
Interacting via cell phones, tablets, laptops, or computers, we can help
clients to approach all sorts of feared and avoided situations, activities,
and objects during a session.
Exposure and Panic Attacks
The TFACT approach to panic attacks is summarized in the choice point
diagram below. The away moves listed are behaviors that many people
tend to do during a panic attack, primarily to try to avoid or get rid of
unwanted thoughts and feelings. Clients learn to drop anchor, defuse
from thoughts such as I’m going to die/pass out/go mad/have a heart
attack, accept the physical sensations and urges of anxiety, act on their
values, and focus on their values-guided activity. When they are
responding this way, they may still have feelings of anxiety, but they are
no longer having a “panic attack.”

I’m going to illustrate the TFACT approach to exposure for panic

attacks using the case example of Sergio.
Sergio was a thirty-four-year-old single male—a senior executive in
a large manufacturing company. He presented with common symptoms
of PTSD and panic disorder. His issues stemmed from a hiking accident
nine months earlier in which Sergio’s best friend slipped off a narrow
mountain pathway and fell to his death. We’re going to look at extracts
from session six. By this point, Sergio was quite skillful in dropping
anchor and had developed basic abilities in defusion and acceptance
(although he was still resistant to self-compassion).
 The figure below illustrates Sergio’s thoughts, feelings, sensations,
and urges (at the bottom of the choice point); his problematic responses
(i.e., away moves); and the new, more effective responses (i.e., towards
moves) he worked on developing through exposure.

Motivation
Sergio’s values-based motivation for exposure was documented
alongside the towards arrow of the choice point. Throughout exposure,
his therapist would frequently return to these values and goals to remind
Sergio of the purpose for this challenging work.

Psychoeducation for Panic Attacks

Psychoeducation about the cause and nature of panic attacks always
precedes exposure. There are three main aspects to this (all of which the
therapist covered with Sergio):

1. HOW STRUGGLING WITH ANXIETY

AMPLIFIES IT
 First, we introduce the struggle switch (chapter twelve) to illustrate
how struggling with anxiety amplifies it. Then:
Therapist: So now even the slightest trace of anxiety—and even
physical sensations that have nothing to do with
anxiety, like when your heart is racing after exercise—
will trip your struggle switch. Which instantly amplifies
whatever anxiety is present. And hey, presto, the
vicious cycle starts: anxiety about anxiety about
anxiety, ending with a full-blown panic attack.

2. WHY IT FEELS DIFFICULT TO

BREATHE
Most clients feel unable to breathe properly during panic attacks. So
we explain:
Therapist: What happens is, you’re breathing in and out so fast
—hyperventilating—that your lungs don’t have time to
empty. It takes quite a few seconds to empty all the air
from the lungs, and you’re not giving it that long. So
basically your lungs are still half full of air when you
start taking your next breath—which means it’s very
hard to breathe in, because there’s all that air already
inside your lungs, taking up space. So what you need
to do if you feel like you can’t breathe properly is the
complete opposite of what your mind is telling you: you
need to actually breathe out very slowly and very
gently, and ever so slowly, empty your lungs. Then,
you’ll be able to breathe in.

3. THE SENSATIONS OF
HYPERVENTILATION ARE UNPLEASANT
BUT HARMLESS
 Therapist: Another thing that happens when you hyperventilate
is that you breathe out lots and lots of carbon dioxide—
so the level of carbon dioxide in your bloodstream
drops to way below normal. And that then triggers a
complex biochemical chain reaction that ends up
altering the blood flow in different areas of your body—
more blood to your face, so you flush; less to your
fingers and brain, so you get pins and needles, or
dizziness. The thing is, although that feels very
unpleasant, it’s actually harmless. But your mind thinks
it’s dangerous—so whoosh, up goes your anxiety.

Defusion
With Sergio, psychoeducation was followed by some defusion
practice. Sergio noticed and named his most troublesome thoughts as
“I’m going crazy” and “I’m having a heart attack.” The therapist
normalized these (we all have thoughts about bad things happening) and
looked at their purpose (your mind trying to protect you, keep you safe).
Next the therapist emphasized, “These thoughts will keep coming
back. Your doctor gave you a full check-up, your blood tests were fine,
your ECG is healthy, your heart is great—and each time you’ve been to
the emergency department, the doctors have told you you’re fine—but
none of that has stopped your mind from telling you you’re going to
have a heart attack. Same with going crazy; it’s never happened, but
even though you know that, and even though all these doctors have
assured you it won’t happen, those thoughts keep showing up. And
there’s a reason for that; you can never actually disprove those thoughts.
No doctor or therapist can ever 100% guarantee that you won’t have a
heart attack or go crazy; you know logically and rationally that it’s
extremely unlikely, but no one can ever guarantee it—so that gives your
mind wiggle room to say, It still might happen.”
Sergio, following the advice of a popular self-help book, had
vigorously disputed these thoughts many times—telling himself, It’s not
true, It won’t happen, I’ve never gone crazy, The doctors have examined
my heart and it’s fine. And yet—the thoughts continued to occur. The
therapist asked, “So given that these thoughts keep occurring, and your
usual ways of responding to them are taking you away from the life you
want, what might be helpful from the work we’ve already done?”
Sergio decided to use his favorite defusion technique: Aha! Here’s
the panic theme, again. Hey, mind, I know you’re looking out for me—
but it’s okay, I’ve got this covered. The therapist got him to practice this
technique with two of the “stickiest” thoughts—first fusing with them,
then defusing, and Sergio agreed to use this method, if required, during
exposure.

Beginning Exposure
Sergio had good dropping anchor skills, and the exposure session
began with a one-minute version of ACE. Then the therapist encouraged
Sergio to hyperventilate. Within a minute, Sergio was feeling dizzy, hot,
anxious, and tight in his chest.
While encouraging Sergio to continue hyperventilating (for a
minute more), the therapist obtained scores for presence, CPA, and
willingness.
Therapist: Zero to ten, how present are you, right now?
Client: About eight.
Therapist: And zero to ten, how much control do you have
over your physical actions, right now? Have a
stretch, move your arms and legs, check it out.
Client: (stretching and moving) About a nine.
Therapist: Cool. And zero to ten, how willing are you to
have these feelings, right now?
Client: Not very. About a three.
 Exposure and Acceptance
The therapist then worked on acceptance. Key comments from the
therapist (not including Sergio’s responses) are recorded below. Three
dots indicates a pause of around five seconds.
Therapist: So which of these feelings bothers you most?…
Okay, so see if you can just open up and make
some room for it… And notice it with curiosity…
Look at it from all angles, above and below…
Notice the shape and size…
Do you really have to fight with this feeling, or
run from it? Can you make peace with it, even
though you don’t like it?… See if you can let it be
there… Drop the struggle, open up, let it be…
And no need to keep hyperventilating, you can
breathe normally now…
And is your mind saying anything unhelpful?
Yes? Okay—so notice and name those thoughts,
and come back to the feeling… And observe it as
if you’re a curious scientist who has never
encountered something like this before…
And let’s update the numbers again, zero to ten
for each one please—how present? Eight, okay.
Control of your actions? Eight, okay. Willingness to
have this feeling? Five, up from three. Cool. Are
you okay to stay with this a bit longer? Great…
So again, noticing with curiosity…and allowing
it to be there…and remembering why you’re doing
this—courage, self-caring, freedom, expanding
your life to the fullest…and are you willing to make
room for this feeling, so you can do the things you
want to do?… So opening up, making room, letting
it be there, even though you don’t like it… And if
your mind is interfering, notice and name those
thoughts, and come back to the feeling… Opening
up… Letting it be…
 And the numbers again—present? Nine. Actions?
Nine. And willingness? Seven, cool!… That’s great
work. So—no pressure at all—would you be willing
to do that again?

Whichever scales we use, we want the scores to be at least a seven

before moving on to the next round of exposure. If the client is willing to
continue, we repeat the exercise but focus on a different sensation. For
Sergio, there were four rounds of exposure, lasting twenty minutes in
total. Each round focused on a different sensation: dizziness, pounding
heart, chest tightness, a lump in the throat. And the final round ended
with a minute of dropping anchor.

Can Physical Movement Be a

Distraction?
If at any point during exposure a client’s ability to control their
actions drops below a seven, we get them to stretch, move, change
position, reach out and pick up an object, and so on, until it’s back to
seven or higher. Of course, there is a risk that this movement could
distract the client, so we rapidly refocus on the target stimulus:
Therapist: Okay, so five is a bit low; let’s see if you can really
connect with your body here. Have a really good
stretch… And shift your position in the chair… And
move your arms around, wiggle your fingers… And tap
your feet up and down… That’s it… Now what’s the
number? Seven? Great. So really notice this… Notice
the feeling again, it’s right there, and notice that even
with this feeling present, you have control of your
actions, so you can do things that are important… Now
focus in on the feeling again…

What About Breathing Exercises?

 When anxiety shows up, we want clients to drop anchor, make
room for sensations and urges, unhook from thoughts, act in line with
their values, and engage in what they’re doing. (This is precisely what
Sergio’s therapist taught him to do.) If a client is doing all this, they will
be experiencing anxiety—but they will not be having a panic attack.
If clients use a breathing technique for acceptance (e.g., breathing
into and around a feeling to help open up, make room for it, allow it to
be there), that’s okay. But if they breathe in a particular manner to reduce
anxiety, this is risky. Why? Because it easily pulls them back into the
experiential avoidance/emotional control agenda, which is what fosters
panic attacks in the first place. Therefore, breathing to relax should be
discouraged.
Of course, hyperventilation does have unpleasant side effects, such
as dizziness, pins and needles, and facial flushing—and we can teach
clients to reverse these side effects through slow and gentle exhalation,
rebreathing into a paper bag, or biofeedback using a capnometer.
However, if we go down this path, we need to make it crystal clear that
(a) although the sensations are unpleasant, hyperventilation is harmless;
and (b) the breathing techniques are not intended to reduce anxiety; their
purpose is to reverse the harmless but unpleasant physiological effects of
hyperventilation.
If we omit this essential information, confusion is likely, and the
client will likely use these techniques to try to avoid anxiety.

Learning Outcomes and “Expectancy

Violation”
Inhibitory learning theory informs us that one way to increase the
effectiveness of exposure is to maximize “expectancy violation”: the
difference between what you expect to happen and what actually does
happen. The greater this difference, the greater the new learning. So
before an exposure activity begins, the therapist asks the client, “What
do you think might happen as we do this? What’s your greatest fear?”
 Sergio’s reply to this question was, “I think it’s going to be really
difficult. I think I might lose it. It’s going to be very hard. I don’t know if
I’ll be able to do it. I might flip out.”
The therapist does not (as in other models) try to reassure the client,
or challenge their worrying thoughts, or help them make their
predictions more realistic—because this would reduce the degree of
expectancy violation. Instead, the therapist encourages openness and
curiosity: “Okay, so let’s note that that’s what your mind is expecting—
and let’s see what happens.”
After the exercise, the therapist explores the new learning, with
questions like:

So your mind predicted that X, Y, Z was going to happen. How

accurate was that?
What was different than what you expected?
Was it as intense/difficult/challenging/hard to make room for as you
expected?
What did you learn from this? How might that new learning be
helpful for you?

Sergio’s replies to these questions included:

“Well, it was really hard—but no, I didn’t lose it. I didn’t flip out.”
“Yes, it got a bit easier with each round—still hard, but—just, you
know, got a bit easier—and I could flick off the struggle switch
quicker.”
“Well, I didn’t like the feeling…but I found I could have it there
without fighting it.”
“I learned I can control my actions when anxiety is there.”

Note that we don’t focus on the erroneous content of thoughts, nor

advocate disputing them. We focus on what happened during exposure,
and what it was like to make contact with and open up to the target
stimuli. We note the discrepancy between what “the mind” predicted
beforehand and what actually happened—and we use this as an
opportunity to reinforce earlier metaphors such as the Caveman Mind or
the Overly Helpful Friend. We acknowledge: “Your mind will keep
doing things like this—warning you of things that will hurt you. And
sometimes it is spot on with its predictions, but a lot of the time, it’s way
off. And that’s normal. That’s a normal human mind just doing its
number one job: trying to keep you safe.”
Often at this point, it’s useful to quickly recap the core concept of
workability: that although the mind naturally predicts danger
everywhere, we do have a choice about how we respond. We can notice
these thoughts and consider—if we let them guide our actions, will that
take us toward or away from the life we want? And if the answer is the
latter, the client can use the unhooking skills they’ve learned in earlier
sessions.

Ongoing Exposure
After in-session exposure, we encourage the client to practice doing
similar exercises at home. Daily practice for fifteen to twenty minutes (in
one sitting) is ideal, but we need to be flexible; any practice is better than
nothing. So we could start with once a day for ten minutes, or twice a
day for five minutes, or three times a week for three minutes—and build
on it over time. (Light weights first; heavier weights later.) The “Home
Practice” worksheet in Extra Bits and the motivational tools of chapters
sixteen and eighteen (especially the “seven Rs”) come in handy.
Some clients rapidly develop their ability to respond flexibly to
difficult TIMES. For others, progress is slow, and patience is necessary.
Sergio was in the first category. He practiced diligently for ten to fifteen
minutes every day, and within two weeks, his emotional flexibility
significantly improved. He became much better at accepting anxious
feelings and defusing from anxious thoughts, while staying present and
in control of his physical actions. He still experienced anxiety, but he no
longer had panic attacks.
 The next step for clients is to resume activities they’ve been
avoiding—and as they do so, respond flexibly to the difficult TIMES
that arise. For Sergio, this included playing soccer, attending and
speaking up in meetings, and going to crowded social events.

Creating an Exposure Hierarchy

An exposure hierarchy sets out a number of steps, ranging from not at all
difficult to extremely difficult, for the client to follow. We don’t have to
create an exposure hierarchy, but it’s often useful to do so, as it maps out
a clear pathway ahead.
For example, if a client is avoiding work because of a traumatic
incident that happened there, their exposure hierarchy may begin with
driving past the workplace, then going home. (If even this is too
challenging, they may just drive half the distance to work, then go
home.) After a day or two of this, the next step may be driving to work,
parking in the parking lot, staying there for a few minutes, and then
going home. After doing this a few times, the next step may be going
into the building, having a cup of coffee in the staff lounge with a trusted
colleague, and then going home. From there, the next step may be going
back to their office, sitting at the desk, answering a few emails, then
going home after five minutes. And so on and so on, until eventually
they are back at work, on full duty.
The diagram below shows the top of an exposure hierarchy
worksheet (see Extra Bits). In the top row, we write the values and
values-based goals that motivate the exposure. The first column
highlights willingness, the second specifies actions to take, and the third
rates the expected difficulty of doing it.
 Top Part of an Exposure Hierarchy Worksheet

Let’s walk through the steps of completing this worksheet.

Step One: Brainstorm and Rate

Before completing the worksheet, the therapist and client
collaboratively brainstorm a range of actions (usually about ten to
fifteen) that the client could take to reclaim this aspect of life, and the
client rates each one zero to ten in terms of expected difficulty. It’s best
to do this initial brainstorming on a blank sheet of paper because it
usually gets messy: clients often change their minds about the scores, so
we end up crossing out one number and writing in another, which then
alters the position in the hierarchy. Once brainstorming is complete, we
then write the activities on the worksheet, arranged in sequence
according to difficulty. And to save time, we can ask clients to do this
after the session. (It’s fine if several activities have the same rating, or if
there isn’t one assigned for every number.)
Let’s look at an example for a client whose target problem is
avoidance of intimacy.
Sophie is a forty-three-year-old female nurse in a same-sex
relationship. Her past trauma history includes childhood sexual abuse by
her brother, episodes of physical and verbal abuse in two brief
heterosexual relationships in her twenties, and a sexual assault in a night
club by a man who drugged her drink. Her current relationship has been
going on for nine months and is the longest she has ever had. However,
there is very little physical intimacy because it triggers extreme anxiety
(which Sophie wants to avoid). She has basic skills in defusion,
acceptance, dropping anchor, and self-compassion. Before brainstorming
activities, the therapist explained:
Therapist: Remember we talked about working with light
weights before moving to the heavy ones? For
most of my clients with these issues, sex is the
heaviest weight in the gym—whereas holding
hands is a light weight. So can we brainstorm a
range of activities—some easy, some hard, some
in the middle? And the thing is, sometimes even
just talking about the possibility of doing this stuff
can trigger strong emotions or painful memories—
so if that happens, you know the drill?
Client: Drop anchor?
Therapist: Yep!
They then brainstormed fifteen different activities varying in degree
of physical intimacy, and Sophie rated each degree of difficulty. The
table below shows only ten of them.

Extract from an Exposure Hierarchy for Physical Intimacy

 For an experienced therapist, it usually takes about fifteen minutes
to create a ten-to-fifteen item hierarchy. However, it can sometimes take
much longer. If so, we don’t have to complete it all in session; clients
can finish it for homework. The example above took about thirty minutes
because, as anticipated, talking about these activities triggered high
anxiety, and several times they had to put the task on hold so the client
could drop anchor, defuse, and make room for her feelings.
Upon completion, the therapist said, “So we don’t want to start with
the really heavy weights—like seven or above—but we don’t have to
start with the very lightest ones, either. Looking at this list, which would
you be willing to start with?” The client chose “Sitting on couch, thigh-
to-thigh, arms around each other, clothes on”—which she’d rated a four
in terms of expected difficulty.

Step Two: Specify Duration and

Frequency
The next step is to specify how often the client will do this activity
and for how long. This information also goes on the worksheet. Sophie
wrote:
Sitting on couch, thigh-to-thigh, arms around each other, clothes on 4 (10 minutes, 3 x a
week)

Step Three: Check for Willingness

The final step is to check for willingness. A good way to do this is
to ask the client to vividly imagine doing the exposure activity outside of
session. For example, here’s a portion of Sophie’s therapy session:
Therapist: So take a moment to imagine yourself going
ahead with this, as vividly as you can…notice what
you can see, and hear, and touch, and taste…as if
it’s happening right now…and what’s showing up
as you do that?
 Client: I’m scared.
Therapist: And where are you feeling that?
Client: My chest—it’s really tight.
Therapist: Anywhere else?
Client: My throat.
Therapist: And what’s your mind saying?
(The therapist spends a few minutes helping the client accept these
feelings, through more exposure, ending with the Kind Hands exercise.
Then continues…)
Therapist: So if these feelings are showing up now, just
from imagining it, you can pretty much guarantee
that in the real situation, they’ll be there even
stronger. Are you willing to make room for these
feelings, in order to do this?
Client: Yes. I am. This is really important to me.
Therapist: How will your mind try to talk you out of it?
Client: Oh, the usual. It’s too scary. Don’t do it. You’ll get
hurt.
Therapist: Are you willing to make room for those thoughts?
Client: Yes.
Therapist: Okay, let’s write that in then. (Therapist writes Y
—for “yes”—in the willingness column.)
If a client is ever unwilling to do something, we compassionately
and respectfully acknowledge that: “Okay. Thank you so much for being
honest with me. I’d hate for you to ever go ahead and force yourself to
do this stuff if you’re not truly willing.” We then encourage them to
move down the ladder and pick an easier task.
 The ability to focus attention fully on the activity at hand—and
refocus, whenever it wanders—is an important factor for success as the
client undertakes these challenges, so we want to emphasize their use of
this skill (and teach it, if it’s lacking). For example, Sophie found as she
worked through the hierarchy above, she often got distracted by anxiety
or painful memories, which pulled her out of the intimate connection she
wanted; so each time that happened, she noticed and named the
experience, then refocused on her partner. (And naturally, HARD
barriers will surface—which we address as in chapter sixteen.)
But what if a client avoids a desired meaningful activity because it
triggers traumatic memories? For example, suppose a client wants to be
sexually active with their partner but avoids it because they know painful
memories of sexual abuse are likely to recur during it. If so, we first
work with those memories directly, doing exposure as in chapters
twenty-nine and thirty. After that, we use intimate activity for further
exposure, as described above.

A Note on Sexual Problems

The exposure hierarchy above focused on increasing physical
intimacy but did not extend into sexual intercourse because, at this point
in therapy, the client considered that “off the table.” Many clients with
trauma-related issues suffer from sexual problems such as vaginismus,
anorgasmia, dyspareunia, erectile dysfunction, premature ejaculation,
delayed ejaculation, and low libido. Often clients don’t mention these
issues out of shame or embarrassment—even though they cause deep,
ongoing distress. But these issues are common barriers to physical
intimacy: the client avoids it because of the fear it would lead to sexual
activity, which would then expose the aforementioned problems (and all
the difficult emotions, cognitions, and memories that go with them).
The good news is, because fusion, experiential avoidance, and
hyper- or hypoarousal usually play major roles in sexual dysfunction,
many clients find that as therapy progresses and their psychological
flexibility increases, their sexual functioning improves. But if sexual
problems persist, behavioral sex therapy is warranted. For example, a
“sensate focus” program is often extremely helpful. First developed by
Masters and Johnson (1966), sensate focus programs involve a structured
series of intimate mindfulness exercises that couples do together to
deepen connection, tune into their bodies, and increase responsiveness to
their own and each other’s physical, emotional, and sexual needs. If your
clients do TFACT first, the mindfulness skills they develop will
complement and accentuate behavioral sex therapy, if it is later needed.

Variable Exposure
We’ll finish off this chapter with the liberating concept of “variable
exposure.” Older models teach that you need to strictly “move up the
ladder” of the exposure hierarchy, and an activity needs to be repeated
until there’s a 40 to 50% drop in the SUDS score before progressing to
the next level. However, inhibitory learning theory suggests that new
learning is more likely when we don’t follow a strict progression, but
instead practice “variable exposure”: that is, freely moving up and down
the hierarchy, without regard to level of difficulty. So, for example, one
day you may do a task rated five; the next day, an eight; and the day after
that, a three. (However, it’s wise to begin with low-difficulty items to
build confidence and prevent dropout or treatment refusal.)
From a TFACT perspective, if the client is freely choosing to act in
line with their values and willing to make room for all the difficult
thoughts and feelings that arise—we can encourage them to go ahead
with it. In other words, it’s fine for a client to jump straight from an item
rated two to an item rated nine without the need to go through items
rated three through eight—as long as they are willing.

EXTRA BIT In Trauma-Focused ACT: The Extra Bits, chapter

twenty, you’ll find a “Move with the TIMES” diagram, an
exposure record sheet, a “Home Practice” worksheet, and an
“Exposure Hierarchy” worksheet.
Takeaway
TFACT’s exposure principles are the same for all repertoire-narrowing
stimuli—both internal (e.g., cognitions, emotions, urges, sensations) and
external (e.g., people, places, objects, situations, activities).
Compassionate, flexible exposure involves contacting these stimuli and
learning to respond flexibly, in the service of values-based goals.
 CHAPTER TWENTY-ONE.

The Flexible Self

We all have a “self-concept,” or “conceptualized self”: a collection of

narratives, opinions, judgments, and beliefs about who we are, what we
are like, how we got this way, our strengths and weaknesses, our “good
points” and “bad points,” what we can and can’t do, and so on. A self-
concept is useful—but, like any cognitive content, when we fuse with it,
problems ensue. Most commonly, clients fuse with a negative self-
concept: I’m broken, damaged, defective, worthless, incapable,
incompetent, unlovable, and so on. But at times, they may fuse with a
positive self-concept, leading to problems with narcissism, arrogance,
egotism, overconfidence, grandiosity, or entitlement.
Fusion with self-concept can present as “event centrality”: an
individual’s perception that a traumatic event is central to their identity.
The more someone’s identity is based upon their trauma history, the
more severe their symptoms and the worse the prognosis (Boals et al.,
2010). So we want to help clients defuse from this trauma-centric
narrative to experience that “there is much more to me and my life than
these traumatic events in my past.” One way to achieve this is to work
explicitly with self-as-context (Boals & Murrell, 2016). When clients
remain entangled in their self-concept to such a degree that it holds them
back in life (e.g., “I’m too depressed to do that”; “I don’t deserve a better
life”; “Now that I’ve left the army, I’m a nobody”), and defusion
interventions have not been as effective as desired, self-as-context can
make all the difference.
 In chapter thirteen, we explored how self-as-context (the noticing
self) can foster acceptance, through metaphors like The Sky and the
Weather. Now we’ll explore how it can facilitate defusion from the
conceptualized self.

Two Types of Intervention for Self-as-

Context
Broadly speaking, when working with self-as-context (in the sense of
“the noticing self”), there are two types of intervention we use: (a)
metaphors that facilitate defusion from self-referential narratives,
through conveying the message “you are not your thoughts”; and (b)
mindfulness practices that develop the ability to take “the observer
perspective,” enabling you to “step back” and observe cognitions
without getting caught up in them.

Metaphors for Self-as-Context

Popular metaphors for self-as-context include the Chessboard and
Pieces (Hayes et al., 1999) and the Stage Show of Life (Harris, 2009a),
both of which you’ll find in Extra Bits. Here, I’ll share my favorite: the
Documentary of You (Harris, 2007).

The Documentary of You

This metaphor begins by discussing documentaries about the
country in which the client lives.
Therapist: So, I’m guessing you’ve seen quite a few
documentaries about the United States on
streaming services or news channels?
Client: Yeah. Of course.
Therapist: So, what kinds of things have you seen in those
documentaries?
Client: Well, recently, the presidential elections. Donald
Trump, Joe Biden.
Therapist: Right. What else?
Client: Err, well, I guess things like “Me Too” and “Black
Lives Matter.”
Therapist: Sure. What about famous events from the past?
Client: Oh, wars. Like Vietnam…the Gulf War…Pearl
Harbor.
Therapist: Yeah. What about even further back in time?
Client: The Civil War. Abraham Lincoln.
Therapist: Right, and back to the present. Other famous
people, apart from Trump and Biden?
Client: Oh, lots of stuff on movie stars, athletes…Prince
Harry and Meghan Markle.
Therapist: What about nature or travel documentaries?
Client: Oh yeah, Grand Canyon…Monument Valley…Mount
Rushmore…Empire State Building…
Therapist: And animals?
Client: Yeah, grizzly bear…bald eagle.
Therapist: Right. So you’ve seen some pretty positive
documentaries about the US—and you’ve also
seen some pretty negative ones. So, which type of
documentary shows the real United States; the
positive or the negative?
Client: Well, both.
Therapist: I can see why you’d say that. But do you know
how biased those documentaries are? Like, the
camera crews film hours and hours of footage, and
then they cut that down to just a few minutes of the
most dramatic shots, and then they edit it together
to tell an extremely biased story that represents
the viewpoint and prejudice of the director.
Client: Yeah, good point.
Therapist: I mean, suppose I gave you one thousand hours
of the world’s greatest ever documentaries about
the US. Would that be the same thing as the US
itself?
Client: Err, no.
Therapist: What about a hundred thousand hours of
documentaries? Would that be the same thing as
the US?
Client: No.
Therapist: Right. I mean you’d see images that represent
aspects of the US, and you could hear people’s
opinions about certain things going on in the US,
but it couldn’t even come close to the reality—to
actually hiking the Grand Canyon or feeling the
spray on your face from Niagara Falls, or sinking
your teeth into a Coney Island hot dog.
Client: (grimaces) Not keen on hot dogs!
Therapist: Well, there you go, looking at a hot dog in a
documentary, and eating one in real life—those
are two very different experiences, right?
Client: Right.
Therapist: Now the human mind is like the world’s greatest
documentary maker. It’s always filming: twenty-
 four hours a day…one hundred and sixty-eight
hours a week…almost nine thousand hours a year.
So by the time you get to age thirty, your mind’s
been filming for over a quarter of a million hours.
Client: Wow!
Therapist: And what percentage of that film gets stored in
your long-term memory?
Client: One percent?
Therapist: Not even close. It’s like a zillionth of one percent.
I mean how much do you remember of yesterday?
Or last week? Or last month?
Client: (nodding) Good point.
Therapist: So your mind makes this incredibly biased
documentary about who you are—cutting out over
ninety-nine-point-nine-nine percent of everything
that you’ve done in your life—and then it says,
“This is you. This is who you are.” And the subtitle
of that documentary is “You’re not good enough.”
Client: Hmmm.
Therapist: Right. So if a documentary about the US is not
the US, then a documentary about you…is not
you. And no matter what shows up in that
documentary, whether it’s false or true, positive or
negative, ancient or recent, facts or opinions…the
documentary will never be you.
Client: I never thought of it like that.
Therapist: And you know how you can tell that the
documentary is not you?
Client: How?
 Therapist: You step back and watch it. If you can watch a
documentary, you can’t be the documentary.
The Documentary of You metaphor builds on earlier defusion
techniques involving noticing and naming cognitions, and exercises that
involve observing them, such as Leaves on a Stream. And for
homework, we can encourage clients to play with the metaphor:
“Thanks, mind. You’re playing my documentary again”; “Aha! Here’s
the ‘broken me’ documentary.”
However, as discussed in earlier chapters regarding acceptance and
defusion, metaphors by themselves are not enough for clients to develop
new skills.

Mindfulness Practices for Self-as-

Context
To fully develop self-as-context skills, we need to follow self-as-
context metaphors with active mindfulness practices that foster the
experience of the “noticing self.” (In Extra Bits, you’ll find a set of
instructions that you can add to literally any mindfulness practice to
serve this purpose.) So, for example, following an exchange like the one
above, we could say, “So I’m wondering, would you be willing to do an
exercise, now? It’s about learning how to step back and watch that
documentary, without getting caught up in it.” We could then segue into
a mindfulness practice such as the one below.

The Transcendent Self

The Transcendent Self exercise—also known as “the Observer Self”
or “Continuous You” exercise (Hayes et al., 1999)—is often
empowering and liberating for trauma survivors. Because it’s quite
long, we often leave it until later in therapy, when the client has
developed good mindfulness skills. Space doesn’t allow for the
complete script, so I’ve put that into Extra Bits; here I’ve summarized
what’s involved and provided extracts to give you the general idea.
The aim is to help people access a sense of transcendence. In
other words, to experience that no matter what trauma they’ve been
through, and no matter what physical, emotional, or psychological
damage they sustained, a very important part of them, the “noticing
self,” has transcended these events and come through unharmed.
For example, suppose my physical body has been horribly
scarred or deformed; the part of me that notices those scars or
deformations has not been harmed. And suppose I have horrific
memories and painful emotions; the part of me that notices those
memories and emotions has not been harmed. And suppose I have
painful cognitions: I’m broken, damaged, worthless; I can never have
the life I wanted to live. The part of me that notices those cognitions
has not been harmed. Thus, a part of me has transcended the
trauma.
Now if we try to convince the client of this, or explain it logically,
or lecture them about it, it’s likely to backfire; the client could easily
disagree, argue about it, overanalyze it, or even feel invalidated. So
instead, we help the client access this insight through their own
direct experience, via mindfulness practices such as the
Transcendent Self exercise.
This exercise typically comprises several different segments,
each based on five repeating instructions:

1. Notice X.
2. There is X—and there you are, noticing X.
3. If you can notice X, you cannot be X.
4. X is one small part of you. It does not define who you are.
There is so much more to you than X.
5. X changes. The part of you noticing X does not change.

With each segment of the exercise, X varies—typically starting

with your breath, then moving on to your thoughts, emotions,
memories, physical body, and the roles you play. Here’s an example:
Therapist: Take a step back and notice, where are your
thoughts?… Where do they seem to be located?…
Are they moving or still?… Are they pictures or
words? (Pause five seconds.)
And as you notice your thoughts, be aware
you’re noticing…there go your thoughts…and
there you are noticing them. (Pause five seconds.)
If you can notice your thoughts, you cannot be
your thoughts. (Pause five seconds.)
These thoughts are a part of you; but they do
not define who you are; and there’s so much more
to you than these thoughts. (Pause five seconds.)
Your thoughts change continually…sometimes
true, sometimes false…sometimes positive,
sometimes negative…sometimes happy,
sometimes sad…but the part of you that notices
your thoughts does not change. (Pause five
seconds.)
And when you were a child, your thoughts were
so very different than they are today…but the you
who noticed your thoughts as a child is the same you
who notices them now as an adult. (Pause five
seconds.)

We then run through the same steps with the client’s emotions,
memories, body, and the roles they play. We conclude:
Therapist: Your noticing self has been there all this time…and
it’s there right now, noticing my words, noticing your
responses to them…noticing how you feel about what I
say, and whether or not you agree…and more and
more, you can look at your thoughts and feelings from
this space, and see that there’s so much more to you
than these beliefs and judgments and stories about
who you are…and there’s also so much more to you
 than your memories, emotions, and urges…and ever
so much more to you than your physical body and the
various roles you play…so more and more, you can
bring this larger sense of self to your life…to make that
life fuller and more meaningful.
I recommend you read the full script and listen to the audio
recording of this exercise (both in Extra Bits) to experience it for
yourself.

As with every core ACT process, there are many different tools,
techniques, metaphors, and exercises we can use for self-as-context (the
noticing self), so if further work is needed, we have plenty of options.
One of my favorites is the Good Self/Bad Self exercise (Harris, 2019). In
this exercise, clients first fuse with and then defuse from both negative
elements of self-concept (“Bad Self”) and positive elements of self-
concept (“Good self”), so they learn to “hold lightly” all aspects of the
conceptualized self. (For a script, see Extra Bits.)
And a quick tip: if you google “The Guest House,” you’ll discover
an amazing poem written in the thirteenth century by the Persian poet
Rumi. It beautifully and profoundly encapsulates self-as-context through
the metaphor of a guest house, in which thoughts and feelings are the
guests, coming and going. (After working with self-as-context, you may
want to give your clients a copy.)

The Impoverished Self

Some clients, usually those with complex trauma, have such an
impoverished sense of self—such a limited concept of “who I am,”
“what I want,” and “what I care about”—that we actually need to help
them develop a self-concept. There are several strands of work involved
in this process.
For a start, they need to access their feelings, which often requires
mindful bodywork (chapter twenty-two) and the ability to observe,
describe, and allow their feelings (chapter thirteen). They also need the
ability to consciously notice their cognitions (chapter ten). Once they can
access and observe their thoughts and feelings, a whole new world of
self-knowledge opens up for them: they can start to consciously
recognize what they like and don’t like, what they want and don’t want,
and how they really think and feel about things.
Activity monitoring worksheets (chapter fifteen) and mindful
appreciation skills (chapter twenty-seven) are also important: the former
help clients learn more about what they like and want, and the latter help
them to appreciate aspects of life that are meaningful and pleasurable.
And if clients have no sense at all of what they like or want, scheduling
pleasant activities (chapter sixteen) and self-soothing practices (chapter
twenty-three) are usually helpful.
On top of this, it’s usually necessary to learn assertiveness skills—
especially how to say no, make requests, and set boundaries (chapter
twenty-eight). After all, it’s hard to know what you want or need for
yourself if you have no concept of your own rights or you’re constantly
busy meeting the needs of others.
After doing all the above, we can usually get to values in a lot more
depth. Then as clients develop a sense of what they want to stand for in
life, what really matters to them, and how they want to treat themselves
and others, they are more able to flesh out their self-concept.

EXTRA BIT Download Trauma-Focused ACT: The Extra Bits

from the “Free Resources” page on
http://www.ImLearningACT.com. In chapter twenty-one you’ll
find (a) a script and audio recording for the Transcendent Self
exercise, (b) instructions for fostering self-as-context in any
mindfulness practice, (c) a script and animation for the
Chessboard metaphor, and (d) a script for the Good Self/Bad
Self exercise.
Takeaway
Experiential work with self-as-context (the noticing self) facilitates
defusion from self-concept. This enables a more flexible sense of self, no
longer defined or limited by self-referential judgments and narratives. It
also facilitates transcendence: a sense of rising above one’s trauma
history. And on top of all that, it paves the way for formal exposure to
traumatic memories. Clients are more willing to do such challenging
work when they can see their thoughts, feelings, and memories as “a
documentary” and know they can’t be harmed through observing them.
 CHAPTER TWENTY-TWO.

Working with the Body

When humans disconnect from their bodies, they usually experience an

unpleasant sense of lifelessness. They describe this as feeling numb,
empty, hollow, dead inside; like an empty husk, a shell, a zombie, and so
on: a state that’s the very opposite of vitality.
The word “vitality” comes from the Latin word vita, meaning
“life”; it refers to life force, energy, drive, and passion; feeling fully alive
and participating fully in the world. Our bodies keep us alive, and our
feelings remind us we’re alive; so naturally when we disconnect from
them, our sense of vitality is lost. One of our main aims in TFACT is
helping clients get that vitality back, and connecting with the body
(which includes somatic awareness and interoceptive exposure) is
essential for this purpose.

Why Connect with the Body?

Here’s a problem I often encounter when supervising clinicians.
Practitioners have typically read a lot about trauma, and being
knowledgeable about the benefits, they naturally encourage clients to
connect mindfully with the body. The problem is, most clients don’t have
this knowledge—so they find these practices pointless, odd, or “more
therapy bullshit.” They also fear that connecting with their body will
bring them into contact with unpleasant sensations, emotions, or
memories—experiences they have tried hard to avoid. Either way, they
are often reluctant to do the work involved.
So we need to clearly communicate how connecting with their body
will help the client achieve their therapy goals. If we skip this or do it
poorly, we can expect confusion or resistance. We may begin by
explaining, “Our emotions are generated by nerve signals, which mostly
come from muscles and organs inside our body and travel upward to the
brain. That’s why when we really feel an emotion intensely—like anger
or fear or love—we feel it in our body. So the more you cut off from
your body, the less aware you’ll be of your emotions and feelings.” We
flesh this out with a relevant example (e.g., the racing heart, tight chest,
and knotted stomach of anxiety) and then go on to highlight whichever
of the nine points below are clearly relevant to the client’s therapy goals.

1. Vitality
Clients may complain of feeling dead, lifeless, numb, empty, shut
down—and may even turn to self-harming behaviors, such as cutting
themselves or taking stimulants to “feel something.” We may then say,
“One of the big benefits of learning to reconnect with your body is that
over time, it will give you a sense of vitality, coming back to life, feeling
fully human.”

2. Joy and Pleasure

We may explain, “Cutting off from your body helps avoid painful
feelings—but also cuts you off from pleasurable emotions and feelings,
like joy and happiness. So learning to reconnect with your body will give
you access to the full range of emotions and feelings—both painful and
pleasant. It will enable you to experience pleasure, love, and joy, as well
as sadness, anger, and anxiety.”

3. Control over Your Actions

 We may explain, “The less aware you are of your emotions, the less
control you have over your actions—over what you say and do, and how
you react. If we’re not aware of our feelings, they jerk us around like a
puppet on a string.” To clarify this, we can bring in the Kids in the
Classroom metaphor (Harris, 2015).

Kids in the Classroom

Therapist: Remember when you were a kid and your teacher left
the classroom? What happened? All hell broke loose,
right? Well, it’s the same thing with our emotions. Our
awareness is like the teacher, and our emotions are
like the kids. If we’re not aware of our feelings, they act
up, create havoc, run wild. The less aware we are of
our feelings, the more they control our actions; they
jerk us around like a puppet on a string and easily pull
us in to problematic patterns of behavior. When the
teacher returns to the classroom, the kids immediately
settle down. Same deal when we bring awareness to
our feelings; they lose their impact and their ability to
jerk us around. They’re still there, but they don’t control
us.

4. Wise Choices, Good Decisions

We may explain, “For effective decision making, and for generally
making wise choices in life, we need access to our feelings and
emotions. But the more we cut off from our body, the less access we
have, so the more likely we are to make unwise choices or decisions.”

5. Intuition, Trust, Safety

We may explore with clients how intuition is strongly dependent on
access to our feelings. We may say, “Think of those ‘gut feelings’—
about whether you can trust someone or not. We can’t access our gut
feelings if we’re not tuned in to our body. And more importantly,
feelings in your body often alert you to threats and dangers that your
conscious mind is not picking up. So without access to this information,
you may unwittingly put yourself at risk.” We would link this explicitly
to relevant client issues, such as repeatedly falling into dangerous
situations or having relationships with untrustworthy people.

6. Safety in Your Own Body

We may explain, “If you ever want to feel safe in your own body,
you have to start exploring it and discovering better ways to handle the
difficult feelings that are ‘in there.’ As long as you avoid doing this, you
will never feel safe in your own body: it will be like a dark cave full of
monsters that you want to avoid at all costs.”

7. Success in Life
We may explain, “There is a direct correlation between success in
life and what psychologists call ‘emotional intelligence,’ which basically
means being aware of your emotions, noticing how they affect your
behavior, and learning how to handle them more effectively. Research
shows that if you want to be more successful in almost any area of life—
as a parent, partner, in work or at play—the higher your emotional
intelligence, the greater your likely success. And probably the fastest
way to improve your emotional intelligence is learning to tune into your
body and access your emotions.”

8. Relationships
We may explain, “If we want to build strong, healthy relationships
with other people—whether that’s a partner, friends, children, family,
and so on—we will be at a huge disadvantage if we don’t have full
access to our full range of emotions. Because building good relationships
requires emotional intelligence, not just in terms of our own feelings, but
also being able to tune into and handle the feelings of others.”
We can flesh this point out with the following metaphor: “Have you
ever watched part of a movie on TV without any sound? It’s not very
satisfying. The images may be great, but without music, or dialogue, or
sound effects, you lose a lot of the experience. And if you watch
carefully, you can still keep track of what’s happening to some extent,
but it’s easy to misread what’s going on. And that’s what it’s like when
we interact with others while we’re cut off from our feelings. We can
easily misread what they want or don’t want—their intentions, their
feelings—and we easily lose track of how our behavior is affecting
them.” We then link this metaphor to relevant examples of the client’s
interpersonal problems.

9. Love and Intimacy

This final point will be relevant for many clients with relationship
problems. We may say, “If you’re in a loving, caring relationship, when
you have those moments of genuine loving connection and intimacy, it
usually gives rise to pleasurable feelings. But if you’re cut off from your
body, you won’t get to enjoy them. Instead, you’ll feel numb or empty,
which makes intimacy and connection unpleasant—and feeds into that
sense of disconnection and loneliness. And then because it’s
uncomfortable, you often end up actively avoiding intimacy. So by
cutting off from pain, you also cut off from love.”
The rationale we give for connecting with the body will vary from
client to client, depending upon their unique situation—but at least some
of the points above will be relevant to most clients. The key thing is to
always link it clearly and directly to the client’s therapy goals.

Tuning In to the Body

In TFACT, we help clients develop somatic awareness (the ability to
mindfully tune into the body) right from the word go. This begins with
dropping anchor—both the Acknowledge and Connect phases—and
develops further through acceptance, self-compassion, and interoceptive
exposure. However, we often need to go further, especially with clients
who experience numbness.
There are four main ways to help clients tune into and connect with
their bodies:

Mindful movement and stretching

Mindful body scans
Mindfulness of posture
Mindful self-touch

Before we discuss these methods, a reminder about graded

exposure: begin by helping clients tune into “safe zones” of the body,
and “safe sensations” within those areas. Then, if the client is willing,
help them move up the exposure hierarchy to more challenging areas and
sensations. And as difficult cognitions, emotions, and sensations arise,
help clients stay within their window of flexibility by using their skills in
dropping anchor, defusion, acceptance, and self-compassion.

Mindful Movement and Stretching

In session, we can encourage clients to do brief mindfulness
exercises, focused on moving and stretching. The Connect phase of
dropping anchor already includes this a little—but we can extend it
much further:
Therapist: Now hold that stretch…and notice what that’s like…
tune into it…notice the sensations of stretching as if
you’re a curious child who has never encountered
something like this before… Where are the feelings
strongest?… Are they changing in any way?… Can
you notice any tingling, pulsing, vibrating?… Can you
 notice any increase in temperature?… And can you
notice what’s happening in the adjacent areas of your
body?… And, being careful not to injure yourself, are
you willing to go a bit further into that stretch?… That’s
it… And noticing that sense of opening up… Noticing
the muscles lengthening… Noticing the sensations
changing…
In addition, we can encourage clients to experiment with Eastern
mindfulness-based practices that center on movement and posture, such
as yoga and tai chi, and to mindfully tune into their bodies when doing
sporting activities—especially when these include stretching. And when
clients notice tension or knots or stiffening in various muscles, we may
also encourage them to mindfully stretch (or massage) those areas in
session.

Practical Tip
In chapter thirteen, I mentioned a facet of acceptance called
“harnessing”: actively utilizing the energy of an emotion,
channeling it into purposeful activity. When clients are very
anxious, they may start shaking or trembling or become restless
and fidgety. We can explain these reactions as byproducts of the
fight or flight response: “This is your nervous system, priming
your body for action.” And then we can invite them to channel
this energy into physical movement.

For a fit, healthy person (without chronic pain, physical injury, or

other factors that limit activity), we may encourage them to run
on the spot or do squats. And for the upper body: swinging arms
around, or raising arms and clapping hands above the head, or
even (in fit, strong people) doing push-ups. We encourage
clients to do this mindfully until they get the sense of “expending
all that pent-up energy.” Usually, this takes a few minutes, and it
promotes both acceptance of the anxiety and a rapid reduction
of shaking and trembling. Once the exercise stops, the client is
 typically calmer, and their shaking or trembling significantly
lessens or stops.

Mindful Body Scans

Mindful body scans are pretty much self-explanatory. They involve
scanning parts of the body (or the whole of it), mindfully tuning into the
physical sensations, acknowledging and allowing them to be there. Like
any mindfulness practice, body scans may vary enormously in duration,
taking anywhere from thirty seconds to thirty minutes. Generally, it’s
best to start with shorter exercises of three to four minutes, and build up
the duration over time. We can then encourage clients to practice these
exercises at home with scripts or audio recordings. (We may then opt to
start sessions with a brief body scan, rather than dropping anchor.)
A quick caution: remembering earlier discussions about trauma-
sensitive mindfulness, consider how each unique client may respond to
lying still, eyes closed, for a prolonged period. Many clients will be okay
with this, but not all. So to play it safe, you may wish to begin with scans
that are eyes-open, involving plenty of movement—such as progressive
muscle mindfulness (PMM). This has many similarities to progressive
muscle relaxation (PMR), but there’s one massive difference. The
primary aim of PMR is to relax. However, in PMM there is no emphasis
on relaxation; not one single mention of the word “relax.” In PMM, the
emphasis is entirely on noticing the sensations in your body and
allowing them to be as they are.
For example, in PMR, a typical instruction is:
Therapist: Bring awareness to your feet. Tense the muscles by
curling the toes and the arch of the foot. Keep the
tension there and notice what it feels like. (Pause five
seconds) And now relax. Letting go of the tension…
noticing the new feeling of relaxation.
Conversely, in PMM, the instruction is:
 Therapist: Bring awareness to your feet. Tense the muscles by
curling the toes and the arches of the feet. Keep the
tension there and notice the sensations this creates…
on the top of your feet, and underneath them…and in
your toes. (Pause five seconds) And now, see if you
can, ever so slowly, ease off that tension…and notice
what happens to the sensations in your feet as you do
that…allowing them to be as they are, without any
attempt to change them…and if they do change, simply
noticing the new ones that appear.
In other words, PMM means mindfully scanning your body from
head to toe while tensing and contracting muscles—but with no attempt
to relax (even though this often happens as a side-effect). You can find a
script in Extra Bits, which you’re welcome to share with clients.

Practical Tip
For clients who tend to dissociate easily, especially those who
“freeze up,” encourage them to do PMM standing up, rather
than sitting or lying down.

Mindfulness of Posture
There are many ways of working mindfully with body posture. For
example, we may encourage clients to notice how they are holding
themselves and explore how that feels; or we may give them feedback
about the signals their posture sends. We may also invite clients to
experiment with different stances, postures, and positions and explore
what effects this has (on them and on us). We don’t have space to cover
this important topic here, but I’ve included an entire section on this topic
in Extra Bits.

Mindful Self-Touch
 Mindful self-touch is a powerful way of reconnecting with the
body. Initially, clients may touch, tap, stroke, or massage “safe” parts of
the body, through the clothes. (By “safe,” I mean unlikely to trigger
emotions, cognitions, memories, or sensations that the client is not yet
ready or willing to have.) For example, for clients with a history of
sexual trauma, sexual areas of the body are unlikely to be “safe.”
Naturally, this will vary from person to person, so we always need to
individualize what we do; however, often the arms, forearms, shoulders,
or neck are good places to start.
Some clients may prefer to begin with a firm deep-tissue massage,
their fingers really digging into the muscles and pushing hard. Others
may prefer more gentle self-massage. Yet others may prefer to tap on or
gently stroke those areas. Again, this varies from person to person, so we
always want to ask the client what they prefer and invite them to
experiment with various options, rather than assume we know what’s
best.
The client will initially do “through-the-clothes” self-touch of
“safe” areas in session, for about five minutes, while we encourage them
to tune into the sensations.
Thereafter, clients can create an exposure hierarchy to continue this
work at home. This may involve experimenting with some or all of the
following, listed below in order of (probably, for most people) increasing
difficulty:

Self-touch, through clothes, “safe” parts of the body

Self-touch, bare skin, “safe” parts of the body
Self-touch, through clothes, gradually extending into areas usually
avoided
Self-touch, bare skin, gradually extending into areas usually
avoided

If the client is in a relationship with a supportive partner—and

wanting to increase physical intimacy—then we would encourage them
to experiment with different ways of both touching and being touched by
their partner, especially through structured sensate focus exercises, as
discussed in chapter twenty.

Homework
We can encourage clients to do any or all of these practices for
homework. For clients who have been emotionally numb and deeply
disconnected from their body for a long time, patience is essential.
Although some clients rapidly learn to tune into and reconnect with their
body and their feelings, for others, progress is slow—so much self-
compassion is warranted.

EXTRA BIT Download Trauma-Focused ACT: The Extra Bits

from the “Free Resources” page on
http://www.ImLearningACT.com. In chapter twenty-two, you’ll
find (a) a script for a traditional body scan, (b) a link to an e-
book on working with posture, and (c) a script for progressive
muscle mindfulness.

Takeaway
Working mindfully with the body is an important and central aspect of
TFACT, intrinsic to acceptance, self-compassion, dropping anchor, and
interoceptive exposure. We often go further with body work, using
mindful movement and stretching, mindful body scans, mindfulness of
posture, and mindful self-touch. However, we always need to clearly link
somatic mindfulness—and its benefits—to the client’s therapy goals; if
not, we can expect confusion or resistance.
 CHAPTER TWENTY-THREE.

Sleep, Self-Soothing, and

Relaxation

Many clients lack the necessary skills to establish healthy sleep routines,
soothe themselves when distressed, and relax themselves when tense.
Developing these essential life skills, the focus of this chapter, is an
important part of committed action.

Sleep
Insomnia is an extremely common problem in trauma. Disrupted sleep
can lead to increased irritability, anxiety, depression, daytime sleepiness,
impaired performance at work, low energy, and so on. Clients may be
reluctant to go to bed for fear of nightmares or to avoid a restless night
of tossing and turning. Many resort to drugs, alcohol, or prescription
medication to try to get better quality sleep—but often this just
exacerbates the issue in the long term.
So if we can help our clients improve their quality of sleep, this will
have positive effects on other clinical issues. In Extra Bits you’ll find a
client handout on “Sleep Hygiene,” which covers the main components:

restricting stimulants
maintaining regular sleeping hours
 implementing wind-down rituals before bed
blocking out light and noise in the bedroom
exercising during the day
minimizing pre-bedtime exposure to blue light (e.g., from phones,
computers, TVs)
limiting activity in bed to four things: sex, sleep, mindfulness, and
relaxation

Naturally, when adjusting sleep routines, all the HARD barriers

tend to show up, which we address as in chapter sixteen. We also need to
be crystal clear about the purpose of practicing mindfulness exercises
(e.g., Leaves on a Stream, mindful breathing, Kind Hands, body scans)
in bed:
Therapist: Have you ever tried to make yourself sleep? And
what happened? The more you tried to force sleep, the
less effective, right? So it’s very important not to fall
into that trap here. If you’re in bed, and you’re not
sleeping, trying to make yourself sleep is a recipe for
failure. So instead, the idea is to use that time
effectively. Instead of tossing and turning and worrying,
you practice these skills we’ve been working on. That
way, you’re learning really useful skills that will help
you with many other problems. And the good news is,
these practices are very restful and restorative; not as
much as sleep, of course, but a whole lot more than
tossing, turning, stressing, worrying, and so on. And on
top of all that, there’s often a bonus—when you do
these practices in bed, a lot of the time, after a while,
you fall asleep. So you can enjoy that when it happens
—and when it doesn’t happen, at least you’ll get the
other benefits.
Nightmares are a common problem for clients with a history of
trauma. Imagery rehearsal therapy (IRT) is a cognitive behavioral
therapy for reducing the frequency and intensity of nightmares. The
practitioner first gathers details about the content, frequency, and
emotional intensity of the nightmares, then helps the client to “rewrite”
the nightmares—changing the details so they become less threatening.
The client then mentally rehearses the rewritten nightmares—first in
session, and then at home, daily. Over several weeks, nightmares usually
drop in frequency and intensity or become distress-free dreams. IRT fits
beautifully with TFACT; see Extra Bits for more information.

Self-Soothing
To soothe means to calm, comfort, or provide relief from pain. Self-
soothing involves learning to do this for yourself rather than relying on
others—and, as you’d expect, overlaps considerably with self-
compassion.
In many models, self-soothing strategies are avoidance-based: they
emphasize reducing or removing pain or distracting yourself from it. The
word “relief” comes from the Latin term relevare, meaning “to raise or
lighten.” Pain is a burden, and naturally we strive for relief from it; we
want to “lighten the load.” Many people assume that relief from pain
means removing it, avoiding it, or distracting from it. But mindfulness-
based approaches offer a radically different form of pain relief; this
comes from dropping the struggle with pain, making room for it, and
treating yourself compassionately.
Thus, TFACT-style self-soothing does not aim to avoid or get rid of
pain. It involves calming and comforting yourself through (a) first
accepting your pain and treating yourself in a kind and caring manner,
and (b) then engaging in calming, comforting values-guided activities.

Is Avoidance-Based Self-Soothing
Bad?
There is nothing “wrong” or “bad” about avoidance-based self-
soothing (i.e., doing activities with the primary aim of reducing,
avoiding, or distracting from pain). Undoubtedly, such activities can be
helpful. Remember, TFACT only targets experiential avoidance when it
is so excessive, rigid, or inappropriate that it becomes problematic—in
other words, gets in the way of a rich and full life.
However, if the primary aim of self-soothing is to reduce, avoid, or
get rid of pain, there are times this simply will not work. So in this sense,
acceptance-based self-soothing is superior because we can practice it
whether or not pain reduces. (Of course, pain commonly does reduce
significantly as a by-product of acceptance and self-compassion. That’s
not the aim, but it’s a nice bonus, to be appreciated when it happens.)

When Is Avoidance-Based Self-

Soothing Problematic?
Many self-destructive experientially avoidant behaviors—including
the inappropriate or excessive use of drugs and alcohol, overeating,
gambling, and even (in specific contexts) self-harming—can be viewed
as avoidance-based attempts to self-soothe. So naturally, we validate the
adaptive functions of these behaviors: ‘‘These things have helped you in
the past. They were good strategies, in the sense that they helped you get
through all the bad stuff that was happening and cope with those painful
feelings.” Then we compassionately highlight the costs of continuing to
use them, and once the client sees these behaviors as unworkable, we
explore alternatives.

Self-Soothing Activities
“Soothe” is derived from the old-English word “sooth,” which
means “truth” or “reality.” The first step in self-soothing is simply to
acknowledge the truth or reality that in this moment, life is painful, and
you are hurting. The next step is acceptance, using any technique you
prefer. And the third step, after accepting the emotional pain, is to
initiate a self-soothing activity.
 Any mindfulness-based activity can serve this purpose—especially
those that center on the five senses. Basically, we ask clients what they
find comforting or calming to look at; listen to; smell; taste, eat, or drink;
touch or be touched by; and do physically. The idea is to focus on,
engage in, and actively savor these aspects of present-moment
experience:
Sight: In terms of sight, we may ask clients, “What do you find
comforting, calming, or soothing to look at?” We may prompt them
to consider movies, paintings, sculptures, architecture, fashion, the
sky and the weather, animals, plants, the “great outdoors,” theater,
dance, and so on. And then we can ask, “What self-soothing
activities could you do that draw on sight? For example, could you
watch movies, go to an art gallery, go for a walk in nature?”
Sound: Regarding sound, we may ask, “What do you find
comforting, calming, or soothing to listen to?” We can inquire
about types of music, favorite songs, sounds of nature, voices of
particular people, prayer or chanting, religious hymns, and so on.
And then we can ask, “How can you create self-soothing activities
that draw on sound? For example, could you consider listening to
your favorite music, joining a choir, singing favorite songs,
praying, or chanting?”
Smell: For smell, we may ask clients about food, drink, scent,
aroma, incense sticks, perfumes, freshly baked bread, roast coffee,
the smell of their children’s freshly washed hair, forest flowers,
freshly cut grass, and so on. Self-soothing activities that draw on
smell might include lighting incense sticks, massaging with a
pleasant-smelling hand cream, putting smelling salts in the bath,
baking bread, going for a walk in nature, “smelling the roses,” and
so on.
Taste: For taste, we may explore types of food and drink (that are
life-enhancing rather than self-destructive when consumed). Self-
soothing activities may involve eating or drinking a favorite food
or drink slowly and mindfully and truly savoring the experience
(instead of doing it rapidly and mindlessly).
 Touch: We may prompt clients to consider both self-touching and
being touched by others. This could include brushing hair,
massage, stroking a dog or cat, cuddling or hugging or snuggling
up against loved ones, having their back rubbed or their head
stroked, running their fingers through grass, walking barefoot on
the beach, taking warm showers or hot baths, getting a massage,
and so on.
Physical activities: Last but not least, we can ask clients about
physical activities, such as yoga, meditation, prayer, dancing,
singing, hot baths, playing sports, arts and crafts, woodwork, fixing
up the house, tinkering with the car, writing, reading, acting,
getting out into nature, physical exercise, cooking, visiting
museums or galleries, or gardening.

Experiment, Engage, Appreciate. If the questions above reveal that

clients have little or no prior experience of self-soothing to draw on, we
can ask them to experiment with a range of activities and actively notice
what happens as they engage in them. And we want to clearly emphasize
that the key to making any these activities truly self-soothing is to
engage in them fully—to give the experience their full attention and
actively appreciate it—while allowing their feelings to be as they are.

When Avoidance Creeps In

Despite our best intentions, many clients will do self-soothing
activities with an avoidance agenda—primarily to avoid/escape/distract
from pain. This becomes problematic when (a) the client complains “It’s
not working,” or (b) the client is trying so hard to avoid pain, they don’t
engage in the activity.
In the case of the first issue, always ask what the client means by
“not working.” Usually they will report that the pain is not reducing or
going away—indicating they are misusing it for avoidance. We then
explain, “While self-soothing often reduces pain, it won’t always. It’s a
way to support yourself, comfort yourself, be kind to yourself, in the
midst of your pain. If the pain reduces, as it often does—by all means,
appreciate it; but please don’t make that your main aim, or you’ll soon
be disappointed.”
For the second issue, we revisit creative hopelessness and dropping
the struggle.

Relaxation Skills
If clients don’t know how to relax in healthy, life-enhancing ways, that’s
a significant skill deficit. So we help them develop healthy relaxation
skills, in the service of values such as self-care, self-support, and self-
nurture. You can introduce any relaxation skill you like, from
progressive muscle relaxation or guided imagery to slow breathing or
biofeedback.
However, when we introduce relaxation techniques after several
sessions of TFACT, there’s potential for confusion and mixed messages,
so we need to be crystal clear in our communication. We explain that (a)
this has a totally different aim than all the mindfulness and acceptance
skills, and (b) it’s only likely to work in nonchallenging, nonthreatening
situations. The metaphor of a Swiss Army Knife is useful.

The Swiss Army Knife Metaphor

Therapist: So this skill has a different aim than all the
others. If you think of a Swiss Army Knife, the
other skills are like the cutting blades, whereas this
one is like the corkscrew. It serves a purpose—but
it’s a different one.
Client: How do you mean?
Therapist: Well, with all the other skills, the aim is to let your
thoughts and feelings be as they are; acknowledge
they are there, open up and make room for them,
let them come and go in their own good time; we
 don’t try to control them. But with relaxation skills,
we’re doing the opposite; we’re actively setting out
to cultivate feelings of calm and relaxation. So it’s
important to know this is only likely to work in
nonchallenging, nonthreatening, low-stress
situations. It’s not likely to work in really
challenging, threatening, high-stress situations.
We then give examples of each type of situation—emphasizing
again that in challenging, threatening, high-demand situations, relaxation
techniques are almost certain to fail—so instead, they should rely on
dropping anchor, defusion, acceptance, and self-compassion.

What About Distraction?

“Distraction,” like many psychological terms, can be understood in a
variety of ways, but usually it refers to a class of behaviors that function
as experiential avoidance: deliberately drawing attention away from
unwanted cognitions and emotions to reduce emotional distress.
Flexibly “shifting attention” is different from “distraction.” Contact
with the present moment involves flexibly narrowing, broadening,
sustaining, or shifting attention, as desired. Only when one shifts
attention with the primary aim of experiential avoidance would we call it
“distraction.”
When used moderately, flexibly, and appropriately, distraction can
be helpful. (We all do it!) However, like any form of experiential
avoidance, when distraction is used excessively, inflexibly, and
inappropriately, it becomes a big problem. (Consider: how much of your
own valuable time have you wasted trying to distract yourself from your
feelings? What have been the costs when you used distraction
excessively or inappropriately?)
When we first accept our feelings, and then do some meaningful
values-based activity, and then engage in it fully, that’s an example of
flexibly shifting attention. And this will usually be far more satisfying
than doing that very same activity without acceptance, to distract
ourselves from unwanted feelings. This is because of the paradoxical
effects of experiential avoidance. For example, if you’re trying to
distract yourself from unwanted thoughts and feelings, and they don’t
reduce enough (or they temporarily go away but then rebound), you’re
likely to feel frustration and disappointment. (“I’m still not feeling any
better!”) Or you find it hard to engage in your new activity because you
keep checking in on your feelings to see if distraction is working. Of
course, these things don’t always happen, but the more intense the
emotional pain the client is trying to escape, the more likely they are to
eventuate.
Now having said all that, if you want to teach clients distraction
skills, then you can. If you teach them in the service of values (such as
self-care), they would come under the banner of “committed action.” But
before you go down this path, there are three things to consider:

Clients already have many ways of distracting themselves—and as

we explored in creative hopelessness, these methods aren’t giving
them the long-term results they want. So there’s a real danger of
providing “more of the same.”
If we’re using dropping anchor skillfully and flexibly, along with
acceptance-based self-soothing, distraction isn’t needed to cope
with emotional distress. (I’ve been practicing ACT for almost two
decades, and so far, I’ve never once needed to teach a client
distraction.)
As with relaxation, there’s a danger of confusion and mixed
messages. So you’d need to be crystal clear about how distraction
differs from other skills, such as defusion, acceptance, and dropping
anchor. Again, the Swiss Army Knife metaphor is useful.

EXTRA BIT Download Trauma-Focused ACT: The Extra Bits

from the “Free Resources” page on
http://www.ImLearningACT.com. In chapter twenty-three you’ll
find client handouts on self-soothing and sleep hygiene, and
information on imagery rehearsal for nightmares.
Takeaway
Many clients benefit from developing skills in sleep hygiene, self-
soothing, and relaxation. Distraction is not “forbidden” in TFACT but is
rarely if ever needed. When we introduce relaxation or distraction, we
need to be crystal clear about how these techniques differ from
mindfulness and acceptance skills, to prevent mixed messages and
confusion.
 CHAPTER TWENTY-FOUR.

Working with Shame

Many of us have been taught that shame is demotivating—that it makes

people shut down and avoid dealing effectively with their issues—
whereas guilt is motivating because it helps people recognize they’ve
done wrong and drives them to atone or amend.
The TFACT stance on this is somewhat different. From a TFACT
perspective, no emotion is inherently “good” or “bad,” “positive” or
“negative.” Problems don’t happen because of the emotions themselves,
but because of responding to them inflexibly. So if clients respond
inflexibly to guilt (i.e., with fusion and avoidance), then it’s likely to
demotivate them, hold them back from values-based living. On the
flipside, shame can be a powerful and effective motivator for life-
enhancing change, once clients learn how to respond to it flexibly, which
is the main topic of this chapter.

First Steps
The fivefold strategy of notice, name, normalize, purpose, workability is
a useful place to start with any difficult emotion. Noticing, naming, and
normalizing need no further elaboration, so let’s consider purpose and
workability.

Purpose
 If we respond to it flexibly, shame can motivate us to repair social
damage and cease behaviors that alienate others, illuminate the
importance of treating others well and belonging to the group, and
communicate “I have failed” or “I am defeated.” So rather than treating
shame as the enemy, we can explore how it has aided the client in the
past. It will often have had at least some of the following benefits:
Reducing hostility: If we look ashamed to others, this often lessens
the degree of their hostility, aggression, criticism, punishment, or
judgment.
Eliciting support or kindness: If others know we feel ashamed, this
may elicit their sympathy, kindness, support, or forgiveness.
Avoiding pain: Often, in the grip of shame, we avoid people,
places, situations, events, and activities that trigger difficult
thoughts, feelings, and memories—especially fears of negative
evaluation, rejection, or punishment. In the short term, then, shame
helps us escape or avoid pain.

Workability
As with any emotion, we want to explore:
A. What does the client typically do when shame arises?
B. How does that work in terms of building the life they want?
When shame shows up, most clients respond with fusion in some
situations, avoidance in others. Fusing with the cognitive aspects of
shame—I’m bad, I’m worthless, I deserve to be punished—commonly
leads to social disengagement or withdrawal, self-punitive actions, or
judgmental rumination about one’s flaws and failures.
Experiential avoidance, on the other hand, may involve any of the
usual suspects—from drugs and alcohol to distraction and self-harm.
(Interestingly, some clients use anger and aggression to avoid shame.
This is not a conscious strategy, but it’s highly reinforcing because it
makes people feel strong and powerful—a quick escape from the sense
of weakness and inadequacy fostered by shame.)
Usually clients readily see that these are not workable ways of
responding to shame. So we then identify more workable behaviors,
using any of the methods we’ve covered in earlier chapters.

Skill Building
Typically, the first active skill we teach is dropping anchor—which
immediately helps to “break the grip” of shame. From there we move to
other core ACT skills: defusion from harsh self-judgments; acceptance
of sensations and urges; and, most importantly, the “ultimate antidote” to
shame: self-compassion.
In addition to building skills, psychoeducation and values work are
both very important.

Psychoeducation
We can help encourage defusion, self-acceptance, and self-
compassion by looking at the client’s history. For example, did the
client’s caregivers or abusers or assailants say things that fueled shame
(e.g., “You deserve this,” “You’re a slut,” “You brought this on
yourself,” “You should be ashamed of yourself”)? In cases of childhood
abuse by a caregiver, the following psychoeducation is essential:
Therapist: The thing is, a child has to maintain a positive view of
her caregivers—no matter what they do wrong—
because they are the child’s life support system. And
it’s not like the child consciously thinks this through. It’s
an automatic, unconscious self-protective mechanism.
Because if the child consciously acknowledges that
their life support system is a source of threat and
danger, well, that’s just terrifying. So when caregivers
are abusive or neglectful, the child’s mind automatically
 and unconsciously blames the child for it: It’s my fault.
That’s how a child’s mind protects them from a
terrifying and painful reality.
Another essential piece of psychoeducation, specifically for sexual
abuse, revolves around pleasure. Some clients feel deeply ashamed
because they experienced pleasure or became sexually aroused during
the abuse; the false narrative goes along the lines of “I enjoyed it” or “I
must have wanted it” and therefore “It’s my fault” or “I’m a freak.”
Some people can even experience orgasm during sexual assault—even
though they were in pain, terrified, and hating it. We explain that these
are involuntary physiological responses of the body; they have nothing
to do with desire or enjoyment or “wanting it.”
Therapist: Our sexual organs are built to get aroused or give
pleasure when they’re stimulated in certain ways. And
we don’t control that. Feeling pleasure or getting
aroused doesn’t mean you enjoyed it or wanted it. It’s
your body responding the way it’s been designed to.
It’s like, some people are extremely ticklish, and
absolutely hate being tickled—but when you tickle
them, they laugh; and they’ll keep on laughing—even
while hating it and begging you to stop. Or sweating:
it’s not up to you how much your body sweats; it’s a
physiological response, outside of your control. So in
no way do those automatic physiological reactions
mean that you enjoyed it, wanted it, or made it happen.
Yet another common issue involves clients who “froze” during their
trauma—and are now ashamed that they didn’t fight or run. Brief
psychoeducation about the freeze/flop response is invaluable, and after
this we say: “Knowing this won’t get rid of ‘It’s my fault’ or ‘I’m bad’
or similar themes. They will keep popping up. But at least now you
know the facts.” From this point on, we can refer to narratives like “I’m
bad” or “It’s my fault” as “old programming” to facilitate defusion:
“There’s some more old programming showing up.”
 Values Work
Shame may relate to things the client has had done to them—or to
things they have done to others. Either way, important values are usually
sitting just beneath the surface, and gentle questioning can quickly tease
them out. We may ask:

What does this feeling tell you…

that you deeply care about?
that you want to take a stand against?
that you want to stand up for?
that you want to do differently, going forward?
about the way you ideally want to treat yourself or others?
about what you need to address, face up to, take action on?

Any such questions can start a rich discussion that unearths values,
which then become a springboard for new, effective actions. Through
this process, shame can become a powerful motivator for values-guided
behavior. This is very empowering; we can’t change the past, but we can
learn from it—and the wisdom thereby gained is a useful resource.

Scrunching Emotions
We’ll finish this chapter with one of my favorite exercises:
Scrunching Emotions (Harris, 2015). Although it focuses on shame,
we can adapt this for any painful emotion, to foster acceptance and
self-compassion and connection with values. (Like Pushing Away
Paper, it isn’t suitable for people with neck, shoulder, or arm issues.)
In the script, three dots indicate a pause of about three to five
seconds.

Step 1: Write
The client identifies a shame-triggering memory to work with. On a
sheet of letter (or A4) paper, they write a few words (maximum of
one sentence) to summarize it.

Step 2: Scrunch
Therapist: Now scrunch that up—the memory, and all the
thoughts and feelings that go with it—and make it as
small as you possibly can. Scrunch it really hard, no
half measures… That’s it… Now put it between your
palms, and use both arms and hands to try to squash it
even smaller… Push as hard as you can…and keep
pushing.

Step 3: Squeeze
Therapist: Keep the pressure on, squeezing hard… Hard as you
can… Making it as small as possible… And notice what
this is like… How tiring is it?… How distracting is it?…
How hard to do the things that matter, or engage in
what you’re doing?… How much time and energy have
you spent trying to do this in your life?… And isn’t it
exhausting?… Given there is no “delete button” in the
brain, no way to simply make this disappear, would you
be open to trying something different?… You would?
Great!

Step 4: Hold It Gently

Therapist: Now hold it as if it’s a crying baby, or a whimpering
puppy, or the hand of a loved one who is in deep
distress… And notice the difference that makes… Is
there some relief for you in this?… Is it less distracting,
less tiring?… Notice how much more energy you have
now to put into doing things that are meaningful…
Step 5: Consider What It Tells You
Therapist: Keep holding it this way, and consider: What does
this tell you that you care about?… What values does
this remind you of?… And also consider… You can’t
change the past, but you can influence the future… So
going forward, what do you want to do in the world to
make it a better place?… To help prevent things like
this from happening again?

Step 6: Appreciate It
Therapist: Notice that when you hold it this way, this emotion
can be your ally…reminding you of your values…
motivating you to behave like the person you want to
be… And even though it hurts like hell, it’s giving you
valuable information… This emotion comes about
through your mind, brain, and body working together, to
look out for you… So even though it hurts, see if just
for a moment, you can appreciate it.

Step 7: Squeeze, Then Ease

Therapist: Now just for a few moments, go back to trying to
squash it… Again, crush it hard; both hands, both
arms, crushing it as hard as you can… And keep the
pressure on, full strength, and notice how tiring this
gets… And now, once again, hold it gently…like a
crying baby, or a whimpering puppy, or the hand of a
loved one in distress… And notice the difference… And
cup it gently in both hands…and imagine the space
around it filling up with warmth and caring and
kindness…

Step 8: Self-Compassion
 Therapist: And see if you can send this same warmth,
caring, and kindness to yourself… Imagine it as a
kind of energy…that flows from the cup of your
hands…and flows up your arms and into your
heart…and from there, flowing up and down your
body…and wherever there is pain, tension, or
numbness, this warm, kind energy flows into those
areas…softening up and loosening up around
them.
(The therapist now helps the client zoom in on specific areas of
pain, tension, or numbness, and work with them as in other acceptance
and self-compassion exercises: acknowledging pain and responding with
kindness.)

Step 9: Drop Anchor and Debrief

The exercise finishes with a minute of dropping anchor. We then
debrief it, exploring the impact of acceptance and self-compassion
and teasing out values.

Takeaway
We can use TFACT with any difficult emotion, to transform it from an
enemy to an ally. Although we have focused here on shame, the same
strategies apply for anger, sadness, fear, anxiety, guilt, jealousy, and so
on.
 CHAPTER TWENTY-FIVE.

Moral Injury

When for one reason or another, someone experiences repeated or major

violations of their own morality (e.g., when a soldier is ordered to shoot
civilians, or a worker helplessly witnesses systemic bullying and
discrimination in the workplace, or a young man fails to stop his friends
from violently beating up an innocent person), it can have profound
psychological effects.
“Moral injury” refers to psychological damage sustained when one
perpetrates, witnesses, or fails to prevent an act that transgresses their
moral principles. It was first described in the US military, when service
members returned from the Vietnam War with trauma-related symptoms
that didn’t fit a diagnosis of PTSD; they presented primarily with strong
emotional reactions of shame and guilt, rather than fear and anxiety.
Since then, moral injury has been reported in doctors, nurses, teachers,
and in many other professions. (However, it can also result from
traumatic events that have nothing to do with work—for example, failing
to report knowledge of a sexual assault.) In this chapter, we’ll explore
how TFACT can lessen the impact of moral injury.

Pain Versus Injury

In many texts on moral injury, the terms used are somewhat vaguely
defined. For the sake of clarity, here are some ACT-congruent
definitions:
 Values: desired qualities of behavior (without any judgment of
“right” or “wrong”)
Morals: principles or standards of “right” and “wrong” or “good”
and “bad” behavior
Moral values: values that are judged by one’s society or
community to be right and good, also known as “virtues.” For
example, many societies and communities would judge values such
as honesty, fairness, respect, kindness, and integrity to be “right,”
“good,” or “virtuous.”
Moral pain: painful cognitions and emotions (especially shame and
guilt) that arise when one’s moral principles are violated.
Moral injury: psychological, spiritual, or social damage that results
from responding inflexibly to moral pain.

A Normal Reaction
Moral pain is a normal, natural reaction when one’s morals are
violated. In our own lives, we’ve all experienced the stress and anxiety
of moral dilemmas: “What’s the right thing to do?” And we all know the
angst that results when we don’t “do the right thing”: the guilt, shame, or
regret that arises when we compromise our own moral standards.
In addition, as practitioners, we’ve all experienced moral pain when
we know our clients are victims of injustice, being abused by “the
system,” or being mistreated by others, yet, for one reason or another, we
are unable to intervene.
Depending on the events and the moral principles violated, we can
expect to feel any number of painful emotions, including anger, sadness,
guilt, shame, sorrow, regret, fear, anxiety—and even disgust or
contempt. Likewise, we can expect distressing cognitions to arise—
typically involving themes of injustice, betrayal, unfairness, blame,
criticism of self or others, questions of right or wrong, and so on. These
painful emotions and cognitions are normal, valid reactions, requiring
acceptance, defusion, and self-compassion. And if we respond to them
flexibly, there is no moral injury. Only when we respond inflexibly to this
pain—with fusion, experiential avoidance, and unworkable action—does
moral injury occur.

Presentations of Moral Injury

Moral injury, like any other trauma-related disorder, can present in a
myriad of ways, from depression and suicidality to interpersonal
problems and substance abuse. In particular, we often encounter:

Loss of trust in self or others

Loss of faith/belief (especially religious)
Loss of meaning or purpose in life
Fatalism and nihilism
Spiritual/existential crisis
Doubt, confusion, and questioning about morality
Complicated grief
Resentment and blame
Loss of caring
Feeling “haunted” by the past
Sense of betrayal
Difficulty forgiving
Self-condemnation

The existential, humanistic underpinnings of TFACT make it well

suited to all these issues.

How TFACT Helps with Moral Injury

Our work with moral injury begins, as you’d expect, with lots of
normalizing and validating of the client’s emotional and cognitive
reactions—especially the shame and guilt that usually predominates—
followed by defusion, acceptance, and self-compassion.
Clients often ruminate excessively on many of the themes above:
Things like this shouldn’t happen! The world shouldn’t be like this! Why
do bad things happen to good people? How can God allow this? How
could I have done that? Why didn’t I speak up or do something? What
does that say about me? Thus, when leading into defusion, we might say:
Therapist: The human mind is a sense-making machine. It tries
to make sense of everything—to map it all out, so
there’s a clear path for us to follow. And if the mind
can’t do that, it goes a bit haywire; it goes round and
round in circles, trying to fit all the pieces together, put
everything in the right place. But the problem is, life is
often messy, confusing, chaotic. Bad things happen.
Things we never expected to have to deal with. Bad
things can happen to good people. And good people
can do bad things. And people can do bad things and
get away with it. And people can do good things and
suffer for it. And our minds find that hard to compute. It
doesn’t fit with the way we want the world to be. The
sense-making machine doesn’t like that—so round and
round it goes.
Following this, we can help the client interrupt such rumination, as
covered in chapter eleven. However, we don’t want to dismiss or ignore
these thoughts, so we explore them as below.

Stuck Not Broken

Clients often think their morality has been irreparably damaged. So
the classic ACT saying, “People aren’t broken; they just get stuck,” is
very relevant:
 Therapist: Your moral compass isn’t broken. The fact you’re
suffering so much tells you that it’s still there and
working; if it wasn’t, you wouldn’t be having all this
pain—you wouldn’t care about what had
happened. What’s happened is, you’re getting
hooked by all these thoughts and feelings, and
they’re acting like a blindfold, so you can’t see the
compass. But when you unhook, it’s like lifting up
the blindfold; you’ll be able to see the compass.
Client: You reckon?
Therapist: Well, can we do an experiment to find out?
Would you be willing to do an exercise right now—
to see if you can lift the blindfold and see the
compass?
We could now take the client through a values-clarification
exercise. For example, we could help the client contact their emotional
pain, and then explore: “What does this pain tell you really matters to
you? What it does remind you that you want to stand for, or against?”
much as we do in the Scrunching Emotions exercise, in chapter twenty-
four.

Grief, Forgiveness, and Compassion

for Others
With moral injury (as with many other trauma-related concerns),
there are often issues of blame, resentment, and complicated grief. In
response, we help clients to grieve healthily, practice forgiving, and
develop compassion for themselves and others (see chapter thirty-one).

Meaning and Locus of Control

 Existential themes are often at the core of clients’ struggles with
moral injury. The two existential issues that clients most commonly
grapple with are:

Amid the vastness of time and space, we are small, insignificant,

and powerless.
Life is inherently meaningless.

Working with values, we address both these themes. We give our

lives meaning through connecting with and acting on our values. And the
antidote to insignificance and powerlessness is committed action:
operating within our locus of control. We focus on what we can do, what
we can influence, what we can contribute through acting on our values.
We can’t alter the past, but we can contribute to life in the present, and
play our role in making the world a better place. And if we ourselves
have done wrong, although we can’t change what happened, we can
atone for it, make amends. How? By putting our moral values into play
—in our relationships, our work, or other domains that matter.

Religion and Spirituality

In addition to therapy, many clients find it useful to talk to a priest,
chaplain, rabbi, or Imam or to revisit religious or spiritual texts that have
previously inspired them. However, some turn away from their religious
and spiritual ideology—and this too is a perfectly valid reaction.
It’s often useful to explore clients’ religious, philosophical, and
spiritual beliefs as they relate to the themes we’ve discussed in this
chapter. We want to encourage a flexible perspective on these beliefs: are
they helping the client to adapt, heal, and grow—or the opposite? If the
opposite, we can explore the differences between “rules” and “values,”
and then help clients apply the three strategies for defusion from rigid
rules, covered in chapter eleven.
Takeaway
Moral pain is a normal reaction when one’s moral principles are violated.
When clients respond to that pain inflexibly—with fusion, avoidance,
and unworkable action—moral injury results. As an existential,
humanistic therapy, TFACT is well equipped to handle all aspects of
moral injury—including the existential questions so often raised.
 CHAPTER TWENTY-SIX.

Suicidality

Suicidality—a term that includes thinking about, planning, threatening,

or attempting suicide—is a daunting issue for practitioners. It’s a huge
topic, and we only have space to touch on it briefly, so if you want to
know more, I recommend you read the Clinical Manual for Assessment
and Treatment of Suicidal Patients by Chiles, Strosahl, and Roberts
(2018). In this brief but excellent textbook (from which this chapter
draws heavily), the authors talk about “the three ‘I’s of suicidality.” This
refers to three self-limiting perspectives clients have of their pain:
Intolerable: I can’t tolerate this pain any longer.
Interminable: This pain is always there and never going to end.
Inescapable: Everything that gives me short-term relief from pain
only creates more problems or makes life worse in the long term.
From the perspective of the thee “I”s, life seems unbearable, and if
clients are unable to come up with effective solutions to reduce their
suffering, suicide offers an escape. Thus, beneath suicidality, we usually
find a potent combination of cognitive fusion, experiential avoidance,
and ineffective problem solving.

Risk Assessment
Every practitioner working with trauma should know how to conduct a
suicide risk assessment. (That topic is beyond the scope of this book, so
if you lack skills or knowledge in this area, start by reading the paper
“Scientizing and Routinizing the Assessment of Suicidality in Outpatient
Practice” by Joiner et al., 1999. The authors suggest a risk assessment
based on seven domains: previous suicidal behavior; nature of current
suicidal symptoms; current life stressors; general symptomatic
presentation, including a mood of despair or hopelessness; impulsivity
and lack of self-control; various other predispositions; and protective
factors.) If your client is at significant risk of suicide, you should follow
the guidelines recommended by your professional organization and
workplace. In addition to (but not in place of) those guidelines, this
chapter gives you some ideas for using TFACT.

Strategies for Addressing Suicidality

Suicidal behavior is multifactorial in origin, and all core ACT processes
are relevant and useful in undermining it. Dropping anchor is a good
first-line skill. Four other strategies likely to help are:

defusing from hopelessness and suicidal ideation

using values to find reasons to live
practicing acceptance and self-compassion to handle pain
pursuing committed action with an emphasis on problem solving

Defusing from Hopelessness and

Suicidal Ideation
Yes, you guessed it: to defuse from hopelessness and suicidal
ideation, we again return to the strategy of notice, name, normalize,
purpose, workability.

NOTICE, NAME, NORMALIZE

 When noticing and naming thoughts, we may refer to the client’s
“suicidal thoughts” or “problem-solving thoughts” or “your mind trying
to figure out how to end the pain”—or we may invite clients to come up
with their own names, such as “death thoughts” or the “topping myself”
theme. To normalize them, it’s useful to quote the statistics on suicidality
(Chiles et al., 2018), as follows:
Therapist: You know, research shows that one in two people
become actively suicidal at some point in their life, for a
period of two weeks or more. Think about that statistic
for a moment: one in two, one in two of your friends,
your family, the people on your street, the people at
your work, the staff in your local supermarket…

PURPOSE
Next we look at the purpose of suicidal ideation: it’s a form of
problem solving. We may ask, “What problem is so painful that you’re
trying to kill yourself as a way to solve it?” Whatever the client answers,
we can reply, “That is an immensely painful problem. And your mind is
trying to solve it and stop your pain. And suicide is one possible
solution.”
In other words, we acknowledge that suicidality is an
understandable response to the three “I”s. Consider for a moment: if you
were in great pain, which you truly perceived as intolerable,
interminable, and inescapable, would you think about killing yourself? If
not, you are in the minority. Most people would at least consider it. And
in that moment where someone thinks, I could kill myself and all this
pain would be gone, there will usually be an immediate sense of relief.
To quote the famous philosopher Friedrich Nietzsche, “The thought of
suicide is a great consolation: by means of it one gets through many a
dark night.”
In line with this, we might say to a client, “Right now, your pain
seems unbearable, never-ending, and inescapable; almost anyone in your
shoes would have suicidal thoughts. Your mind is a problem-solving
machine—and every time it generates these thoughts, it’s doing its job—
it’s trying to solve your problems and save you from pain.” This reframe
is enormously helpful for clients racked with guilt or anxiety over their
suicidal thoughts (“Why do I have these thoughts?” “It’s against God’s
will,” “It means I don’t love my children”); it facilitates acceptance,
defusion, and self-compassion.
In addition to experiential avoidance, there are often other
reinforcers for suicidality. So we may prompt the client: “I’m wondering
—do you think your mind may be trying to help you in other ways?”
Compassionate exploration frequently uncovers reinforcers such as:

overt avoidance (i.e., escape from difficult situations)

diminished responsibility (i.e., others expect less of you)
gaining attention, care, support, help, or forgiveness from others
distraction from other painful issues
punishing, hurting, or getting revenge on someone (e.g., a
caregiver)
preventing abandonment (e.g., by a partner)
escaping or reducing punishment
fitting in with or belonging to a group
identifying with an idol or a hero

As these are clarified, we validate them: “So again, this is your

mind trying to help you do/get/avoid these things.”

WORKABILITY
The final step, after validating the reinforcers identified above, is to
explore workability:
Therapist: So when your mind starts getting into the “kill myself”
theme, there are some real short-term benefits of going
along with those thoughts, letting them guide you. But
how does that work in the long term, when it comes to
 things you really want to do with your life, like A and B
and C?
The letters A, B, C represent the client’s values and values-based
goals. If you don’t yet have this information, you can use the generic
phrase “building a better life”—then clarify values, as discussed below.
Take Your Pick of Strategies
The next step is to bring in any of the defusion strategies we’ve
covered. The methods in chapter eleven for disrupting rumination and
worrying are especially useful for suicidal ideation.

Using Values to Find Reasons to Live

Values can help clients find reasons to live even though life seems
unbearable. A good question is, “What has stopped you from killing
yourself so far?” Often clients will mention a beloved cat or dog, their
children, their parents, or their partner; we can then explore those
relationships and tease out the client’s values. Here are three examples:
Therapist: What has stopped you from killing yourself so
far?
Client: My dog, Mira.
Therapist: Mira?
Client: Yeah. She’s the only one who loves me.
Therapist: What sort of dog is she?
Client: A Doberman.
Therapist: Have you got a photo of her?
Client: Yeah. Here. (holds up a picture on her phone
screen)
Therapist: She’s beautiful. How old?
 Client: Three.
Therapist: So even though you’re in all this pain, you’re
staying alive because you care about Mira. What
do you most like doing with her?
(The therapist now goes into the Connect and Reflect exercise.)
Therapist: What has stopped you from killing yourself so
far?
Client: I wouldn’t want to dump that on my kids.
Therapist: Why not?
Client: Because it would mess them up.
Therapist: So even though you’re in all this pain, you’re
staying alive because you care about your kids?
Therapist: What has stopped you from killing yourself so
far?
Client: Because I’m such a loser, I’d probably just screw it
up.
Therapist: And then what would happen?
Client: I’d end up in a wheelchair or something.
Therapist: So life would be even worse than it is now?
Client: Yeah.
Therapist: So notice this—somewhere inside you, amid all
that pain, there’s a part of you that’s looking out for
you, trying to protect you—a part that cares about
you enough that it wants to prevent your life from
getting even worse than it already is.
From here, we can move on to other values-clarification strategies.
The values and values-based goals we help clients discover then become
both “reasons to live” and aids to defusion: “So there’s a caring part of
you—that really cares about things like D and E and F—and then there’s
this ‘kill yourself’ theme that shows up. And there’s a choice to make: if
you want to build a better life, which one are you going to use as a
guide?”

Practicing Acceptance and Self-

Compassion to Handle Pain
Every suicidal client is suffering intensely. So one of our top
priorities is to help them learn how to make room for their pain, respond
with kindness, and soothe themselves. This reduces their suffering and
undermines the experiential avoidance that’s always at the core of
suicidality. Of course, some clients will resist this work, especially if
fused with rules such as “I don’t deserve to live” or “I don’t deserve
kindness” or “I deserve to suffer”; and again, we respond to these as
discussed in chapter fourteen.

Pursuing Committed Action with an

Emphasis on Problem Solving
Most suicidal clients either lack problem-solving skills or are not
applying them. As mentioned in chapter sixteen, we help clients either to
develop these skills or—if they already have them—to apply them more
effectively. We may explain, “Your mind is a problem-solving machine.
But at the moment, it’s so overwhelmed by all your pain and suffering, it
keeps going back to the same old solution: kill yourself and stop the
pain. So to get through this, and start building a better life (even though
your mind says that’s impossible), we’re going to need to ramp up your
problem-solving skills, so you can come up with solutions that actually
help you build a life rather than end it. Can we spend a bit of time on
this, right now?”
Chronic Suicidality and Relapse
In addition to all the above, committed action for chronically suicidal
clients will usually require ongoing training in the following skills:

seeking social support

self-care
crisis coping
impulse control
interpersonal effectiveness (e.g., assertiveness, communication,
negotiation, conflict resolution)

Relapse plans such as the one in chapter thirty-two are also

essential.

Takeaway
As long as clients perceive their pain as intolerable, interminable, and
inescapable, suicidality is likely. But TFACT does not go “on hold” until
suicidality ceases. Rather, suicidal behavior becomes the central focus,
and we bring all the core ACT processes to bear upon it.
 CHAPTER TWENTY-SEVEN.

Finding the Treasure

At the core of all mindfulness practices is the process ACT calls

“contacting the present moment.” In earlier sessions, I’ve emphasized
this as a way to reduce suffering—through dropping anchor, mindful
body scans, and so on. However, we can also use it to enhance pleasure
and fulfilment in life, through mindfully appreciating meaningful or
pleasurable moments. After all, even amid great suffering, there are
times when life gives us what we want—but all too often, we “miss out”
on the potential pleasure or satisfaction of these experiences; lost in our
thoughts, we don’t notice them; or operating on autopilot, we take them
for granted.

Introducing Mindful Appreciation

If we introduce mindful appreciation too early in therapy, it can easily
backfire or rub clients the wrong way, for two good reasons. First, it’s
hard to appreciate anything when you’re emotionally numb or deeply
fused with your suffering. Second, it may come across as similar to
“positive thinking” memes: “Be grateful for what you have,” “Count
your blessings,” “Stop and smell the roses.”
Another problem occurs when clients are still fused with the agenda
of emotional control: trying hard to avoid unwanted feelings, and
craving or clinging to pleasant ones, in the service of their number one
goal—to “feel good.” They are likely to recruit these new skills in that
same agenda—in which case, they’ll soon complain that “it isn’t
working.” So, for example, if clients complain of feeling numb, empty,
flat, or continually in a low mood, it’s not advisable to leap into mindful
savoring exercises too early; usually we need to work first with
acceptance and self-compassion and mindfulness of the body.
However, later in therapy, when clients are living by their values,
willingly making room for their feelings, and being kind to themselves,
it’s a different story. We may introduce mindful appreciation like this:
Therapist: We’ve done a lot of work unhooking from difficult
thoughts, making room for painful feelings, being
kind to yourself, living your values, dropping
anchor, and so on…and I’m thinking it may be time
to look at something a bit different.
Client: Like what?
Therapist: Well, there’s so much pain and suffering in your
life, so many problems and difficulties. And the
thing is, amid all that pain, there are often little,
precious moments you can treasure. And most of
us don’t even realize these things are there—
because we’re on autopilot, or lost in our thoughts,
or struggling with our feelings. So there’s a skill we
can use to spot those treasures, and appreciate
them—because when we do that, it really adds to
our life.
Client: I’m not sure what you mean.
Therapist: Well, for example—you mentioned your sister
has been quite supportive. Was there ever a
moment where you really strongly felt that she was
there for you?
Client: Yeah, at the funeral. I was a blubbering mess. And
she (tearing up)…she held me…she just held me,
for ages, and I sobbed all over her, and she kept
 holding me and stroking my back. (tear runs down
her cheek; face looks soft and warm)
Therapist: So you really felt her…love, kindness…? (Client
nods.) That’s the kind of thing I’m talking about—
moments when there’s something going on, amid
all the pain, that we can appreciate.
Client: Yeah, well—there aren’t many of those.
Therapist: Sure, that may well be the case, but I wonder if
you’re open to doing a couple of short exercises
today, to see if just maybe you can discover some
things in your life you perhaps take for granted, or
don’t get much satisfaction from, and see what it’s
like when you tune in to those experiences and
actively appreciate them.
Client: Okay. I’ll give it a shot.
Note the therapist’s language above; there is no suggestion that this
is about getting rid of or distracting from pain. It’s about appreciating
precious moments “amid all that pain” because it “adds to our life.” With
some clients we may need to be more explicit: “This isn’t a way to
control your feelings; it’s about increasing satisfaction in life by
appreciating aspects that we normally miss out on.”
We also explain:
Therapist: Most people find that the more caught up they are in
their thoughts and feelings, the harder it is to enjoy
life’s simple pleasures—like eating, drinking, hanging
out with a friend. Have you experienced that?
(Therapist gets the client to describe one or two times
when this has happened.) So when we do something in
a distracted, disengaged, or unfocused way, we don’t
find it satisfying—whether it’s playing a game or eating
a meal or listening to music…whatever. But if we can
unhook from our thoughts and feelings, and engage in
what we’re doing, it’s much more satisfying.
Brief Exercises
To help clients appreciate their present moment experience, we can
encourage them to do various activities mindfully in session: eating a
piece of chocolate; sipping cold water; listening to music of their choice;
examining a beautiful ornament; or even leaving the office and going for
a walk, to take in the sights and sounds of the neighborhood. Here’s the
general introduction:
Therapist: So the challenge here is to really pay attention to
everything that you do, and everything that
happens—as if you’re a curious scientist who has
never encountered something like this.
Client: Okay.
Therapist: And as we do this, all sorts of thoughts and
feelings will likely arise, and they can easily hook
your attention, pull it away from the task. So the
aim is to focus fully on the activity. And whenever
you notice your attention has wandered off, take a
moment to note what hooked you, then gently
refocus.
Client: Got it.
My two favorite exercises for this purpose are Notice Your Hand
and Mindful Eating. The former involves a five-minute mindful
exploration of the front and back of one hand—noticing the shapes,
colors, textures, movements, and so on. (For a detailed description of the
exercise and how to debrief it, see ACT Made Simple, 2nd edition, pages
194–197 [Harris, 2019]; for an audio recording, see Extra Bits.) Most
people initially expect this exercise will be boring, tiring, and difficult to
do—but, by the end, find they are appreciative of their hand’s great
complexity and the invaluable role it plays in their life.
For eating exercises, both therapist and client have a small morsel
of food, which they both eat mindfully. Again, most people expect this to
be boring or difficult—yet find themselves astonished by the amount of
 taste in one small morsel. Jon Kabat-Zinn (1982) popularized the use of
raisins, but of course, we can use any food for this exercise. Below is a
basic script; as always, please modify and improvise around it. Allow
around three to five seconds between instructions.

Mindful Eating
Throughout this exercise, all sorts of thoughts and feelings will arise.
Let them come and stay and go in their own good time and keep
your attention on the activity. And if at any point you realize your
attention has wandered, briefly note what distracted you, then
refocus on eating.
Begin by looking at this raisin as if you’re a curious scientist
who has never seen such a thing before. Notice the shape,
the color, the different shades, the contours, the tiny pit where
the stalk was once attached.
Notice the weight of it in your hand and the feel of the skin
against your fingers: its texture and temperature.
Raise it to your nose and inhale…and notice the aroma.
Raise it to your lips and pause for a moment before biting into
it; and notice what’s happening inside your mouth: the
salivation…the urge to bite…
Now slowly bite it in half, noticing how your teeth cut the skin,
sinking into the flesh…and keep hold of one half, and let the
other half drop onto your tongue…and notice the sweetness.
Now let that half-raisin rest on your tongue…and notice the
urge to chew…to swallow…
And ever so slowly, starting to chew…noticing the taste…and
the texture.
Noticing the movement of your jaws…the sounds of
chewing…the flesh of the raisin breaking down…
 Notice how your tongue shapes the food…and your urge to
swallow it…
And now, as slowly as possible, swallowing…and noticing the
sound and movement in your throat…
And notice how the taste gradually disappears…and how your
tongue cleans your teeth.
And notice your urge to eat the remaining half.
So now I’m going to stop talking, and in silence, let’s both eat
the remaining halves of our raisins in exactly the same way.

Debriefing and Homework

After any mindful appreciation exercise, useful questions to ask include:

What did you notice?

How did that differ from the way you normally do this?
What did you get out of it?
What thoughts and feelings hooked you? Were you able to unhook
and refocus?
How can you apply this to other activities in your life?

With prompting, clients usually report awe or wonder or interest,

pleasure or satisfaction, a sense of intense engagement or absorption;
and how this all disappears when they get hooked by thoughts and
feelings; and how it returns when they unhook and refocus. We then
explore the relevance to areas of life clients wish to improve, such as
relationships: What happens when they pay attention fully? What
happens when they get hooked and tune out?
For homework, we encourage such exercises several times daily.
Clients can invent their own or we can make suggestions, as in the
extracts below from the “Life Appreciation Worksheet” (see Extra Bits):
 Savoring Pleasurable Activities
Every day pick a simple pleasurable activity—ideally one you take
for granted or do on autopilot—and see if you can extract every
ounce of pleasure out of it. This might include hugging a loved
one, stroking your cat, walking your dog, playing with your kids,
drinking a cool glass of water or a warm cup of tea, eating your
lunch or dinner, listening to your favorite music, having a hot bath
or shower, walking in the park—you name it. (Don’t try this with
activities that actually require you to get lost in your thoughts,
such as reading a book or doing crossword puzzles.) As you do
this activity, use your five senses to be fully present: notice what
you can see, hear, touch, taste, and smell—and savor every
aspect of it.

Appreciating People
Each day, pick one person, and notice their face as if you’ve never
seen it before: the color of their eyes, teeth, and hair; the pattern
of the wrinkles in their skin; and the manner in which they move,
walk, and talk. Notice their facial expressions, body language, and
tone of voice. See if you can read their emotions and tune in to
what they are feeling. When they talk to you, pay attention as if
they are the most fascinating speaker you’ve ever heard and
you’ve paid a million dollars for the privilege of listening. And very
importantly: notice what happens because of this more mindful
interaction.

EXTRA BIT In Trauma-Focused ACT: The Extra Bits, chapter

twenty-seven, you’ll find an audio recording of Notice Your Hand
and a “Life Appreciation Worksheet.”
Takeaway
We usually bring in mindful appreciation somewhat later in therapy,
because early on it can easily fail, backfire, or be recruited for emotional
control. And it’s something that’s very relevant to all of us because we
all tend to take life for granted, go through the day on autopilot. When
we mindfully appreciate what we have, life is so much richer and more
fulfilling.
 CHAPTER TWENTY-EIGHT.

Building Better Relationships

Rainer Maria Rilke, a famous poet and novelist, wrote, “For one human
being to love another human being: that is perhaps the most difficult task
that has been given to us, the ultimate, the final problem and proof, the
work for which all other work is merely preparation.”
He wasn’t wrong! Even when life is going relatively well, close,
intimate relationships are fraught with challenges. But in the aftermath
of trauma, these difficulties are massively amplified. So let’s take a look
at how TFACT can help. I’ve chunked this chapter into four sections:

Understanding what goes wrong in relationships

Applying TFACT to any relationship issue
Developing relationship skills
Addressing issues of trust

Understanding What Goes Wrong in

Relationships
The chances are, with almost every client, interpersonal issues of one
sort or another will arise. Avoidance behaviors in particular—drug or
alcohol abuse, self-harming, social withdrawal, and so on—often have a
huge negative impact on relationships. In addition, we often see:
 conflict, hostility, aggression
withdrawal, disconnection, avoidance of intimacy
possessiveness, jealousy
excessive seeking of support, reassurance, or approval
passivity, compliance, submissiveness
deceit, dishonesty, manipulation

And the list goes on; almost any fused or avoidant behavior will
impact negatively on relationships once it becomes excessive. Naturally,
when working with any interpersonal issue, we want to know about the
context: What’s the history of the relationship? What makes it better?
What makes it worse? What are the strengths and weakness of both
parties? How does each party contribute to the issue?
Fruitful areas to explore are:
A. What does the client want from this relationship? What are their
needs and desires?
B. What does the client find most threatening in this relationship?
What is the other person saying or doing at those times?
C. What does the client want the other person to start or stop
doing? What strategies has the client tried to achieve that? And
what were the results?
D. What does the client want to contribute to the relationship?
What sort of person do they want to be? What values do they want
to live by? How do they want to treat the other person?
E. Which of their own behaviors does the client see as helpful or
unhelpful? Which of their own behaviors would they like to stop or
reduce? Which behaviors would they like to start or do more of?

Give and Take

 Understandably, many clients are focused on what they want to get
from the relationship and how they want the other person to change.
Often, they haven’t thought about what they want to contribute, what
values they want to live by, or how they might want to change their own
behavior. So it’s essential we raise and explore this, because healthy
relationships require both giving and taking.
Some clients are excessively focused on giving to or pleasing others
—and are not looking after themselves—and this obviously isn’t healthy.
So we help them explore values such as self-care, self-compassion, self-
support, courage, independence, and assertiveness. However, if clients
are excessively focused on their own needs, to the detriment of others—
well, that isn’t healthy either. In such cases, we can help connect them
with values such as caring, giving, fairness, gratitude, and so on.

Validation and Psychoeducation

Functional analysis (chapter seventeen) offers a simple way to
understand and validate any problematic interpersonal behavior. Once
we know the antecedents (situations, cognitions, emotions) that trigger it,
and the consequences that reinforce it (avoidance of something
unwanted, or access to something desired), we can say, “It makes perfect
sense that you would do this.” Validating the behavior does not mean we
agree with it, or it’s justified, or there’s no need to change it. It only
means that it’s understandable: a normal and natural response given the
client’s life history and current circumstances.
With many clients these problematic behaviors (or functionally
similar ones) go way back in time, to early childhood—where their main
functions were keeping the child safe or helping them get their needs met
in abusive or neglectful relationships. And this is where attachment
theory comes in.

Attachment Theory
 Experiencing childhood trauma frequently has a negative impact on
clients’ relationships in later life. Attachment theory helps us to
understand how and why this happens. In chapter fourteen, the section
“Attachment Theory in a Nutshell” covers the main points of the theory.
We can repeat that section almost word-for-word to our clients to
introduce the main concepts, adding, “The reason I’m talking about this
is that our attachment style acts as a sort of guide for the relationships we
form in later life. So if we know a bit about it, that can help us to
understand why we do what we do in our relationships.”
To work with attachment theory, we don’t need an in-depth history
of the client’s childhood; the broad strokes are more than enough.
Indeed, some clients can’t remember their childhood or refuse to talk
about it—and that’s absolutely fine; we can still look at their attachment
style knowing nothing about the past history that shaped it.

ATTACHMENT STYLES
The descriptions below of different attachment styles and their
possible impact on relationships are extracts from the “Attachment
Styles” handout (see Extra Bits), a simple way to explore this complex
subject.
Secure Attachment
The caregiver mostly responds positively, consistently, and reliably
to the child’s “bids,” so the child feels secure in the relationship. This
creates a model for positive, healthy, intimate relationships in later life.
Attitude: “I love you, I care about you, and I’m okay with that. I can
handle a bit of tension or conflict in the relationship because I know
that’s part and parcel of a loving relationship.”
Anxious-Preoccupied Attachment
The caregiver is very inconsistent. Often they respond positively to
the child’s bids—but equally often, they ignore them. So the child is
insecure, anxious, and very uncertain about whether their needs will be
met or not. In later life, this often leads to yearning for attention in
relationships and clinginess, possessiveness, or jealousy.
Attitude: “I’m worried you might not love me, or you might leave
me, and I don’t know if I can rely on you. I really need to know for sure
that you love me, and you won’t leave me.”
Dismissive-Avoidant Attachment
The caregiver rarely responds positively to the child’s bids; most of
the time they are distant and disengaged and ignore the child’s needs. In
response, the child is emotionally distant, comes to expect that their
needs won’t be met, and often gives up trying. As adults, they tend to
avoid seeking nurture, closeness, or caring in relationships and are
therefore often lonely. In fact, often they prefer to avoid relationships
altogether.
Attitude: “I don’t want to care about you deeply or get too close to
you—because if I do, I’ll only end up disappointed, hurt, or lonely.”
Disorganized Attachment
The caregiver rarely responds to bids positively. Most of the time,
they respond with aggression or hostility. As a result, the child is
confused and doesn’t know how to get their needs met. When around
their caregivers, these children often appear wary, anxious, or dazed. As
adults, they find it hard to trust; they are fearful of being hurt, and
closeness brings high levels of anxiety. They have difficulty forming
relationships, and the ones they have are often brief.
Attitude: “I don’t know what I want. Getting close to you scares me.
At times I want to love you; at times I want to leave you.”

ATTACHMENT STYLES CAN CHANGE

We may have different styles of attachment in different
relationships; for example, we may be secure with one parent but
anxious-preoccupied with the other. Also, our attachment styles may
change throughout our lives, either from being in different relationships
or through actively working on our behavior in therapy or coaching.
 We can share the “Attachment Styles” handout with clients and
explore, for this specific relationship:

Which of these styles seems closest to your own?

How does that play out in the relationship?

From there, it’s often useful to focus on two common areas of

difficulty: threats and needs. (Clients may not relate to the terms “threat”
or “threatening,” so consider alternatives like “difficult,” “scary,” or
“stressful.”) We want to find out:

What does the client find threatening in this relationship?

What needs does the client find it hard to meet in this relationship?
What difficult cognitions and emotions show up when the client
feels threatened or their needs aren’t being met?
What does the client do in response to those cognitions and
emotions, and how does that behavior affect the relationship?

WHY INCLUDE ATTACHMENT THEORY?

We don’t have to bring in attachment theory, but it can be useful for
three reasons: First, it raises self-awareness (and can then be used for
noticing and naming: “Aha! Here’s my anxious attachment showing
up”).
Second, it helps clients be more accepting of, forgiving of, and
compassionate toward themselves because they realize they do not
choose these emotional and cognitive reactions; rather, these reactions
result from childhood events that were outside their control. Similarly,
the behaviors they do (in response to those antecedents) make perfect
sense; these behaviors have, in the past, served to protect the client or
meet their needs in difficult situations.
Finally, it helps clients understand behaviors they find odd or
confusing in themselves; it answers their questions like “Why do I keep
doing this?” For example, many clients desire intimacy and closeness,
yet as a relationship deepens, they withdraw physically or emotionally,
or they push the other person away in various ways (e.g., overworking,
having affairs, becoming hypercritical). We help them see that because
of their past history, they find intimacy and closeness threatening, so
naturally, as a relationship deepens, they become increasingly anxious.
Their behaviors help them avoid the threat (of intimacy) by creating
distance and disconnection. (Of course, we can do all of this without
ever mentioning attachment theory, but it does add an extra layer of
understanding.)

THREE CAUTIONS
Three potential problems can occur when we explicitly focus on
attachment theory. One is that sessions can become too analytical and
intellectual. A little bit of insight-oriented work is useful, but generally,
it’s wise to keep discussions on attachment short and sweet (clients can
read up on it later, if interested) and quickly segue into practical skill
building. Understanding and insight play only small roles in behavioral
change; the bulk of the work involves learning new ways of responding
to difficult thoughts and feelings and experimenting with new patterns of
behavior.
A second problem is that some clients think, Well, if that’s my
attachment style, that means I can’t change. So we are clear with all
clients that even when these patterns of behavior are long established
and deeply entrenched, they are still changeable; it requires work, for
sure, but it’s definitely doable.
Third: clients may suddenly recognize the destructive effects of
their own behavior on their children—triggering anxiety and harsh self-
judgment. However, if handled well, these reactions are good
opportunities for growth. Acceptance, defusion, and self-compassion are
good first-line responses. We can then explore the client’s values and
translate them into new patterns of action, in line with the sort of
caregiver they really want to be. (The Scrunching Emotions exercise,
chapter twenty-four, is often helpful.)
Applying TFACT to Any Relationship
Issue
There are four main ways we can use TFACT to help clients with
relationship issues:

1. to take care of themselves and better handle the painful thoughts

and feelings that inevitably show up when relationships are
unsatisfactory;
2. to change what they say and do in their relationships in order to
reduce damage and get better results;
3. to influence the other person’s behavior constructively, in ways
that are healthy for the relationship (e.g., through assertiveness
and good communication); and
4. to end a relationship or develop a new one.

Practical Tip
When a client complains about difficulties in several
relationships, the first step is to narrow the focus. We ask them
to pick just one relationship, we listen compassionately to their
difficulties within it, we validate their concerns and frustrations,
and then we establish behavioral goals:

Therapist: There are a lot of problems in this relationship, and

you’re suffering. So there are basically four things we can work
on here to help improve things. (Therapist briefly runs through
the four options above.) Which of these would suit you best?

Sometimes practitioners are reluctant to run through these

options; they feel uncomfortable or think it’s too directive. But if
your client just keeps venting about all the problems in the
relationship, and this fills up the session so they’re not
developing psychological flexibility or learning new interpersonal
skills, you will need to make room for your discomfort and
actively establish some clear goals, or you won’t get anywhere.

The Tools We Need

Whatever the client’s relationship issues—attachment related or not
—we now have all the tools we need to:

instigate and reinforce any new interpersonal behavior (chapter

sixteen)
undermine any problematic interpersonal behavior (chapter
seventeen)
overcome psychological barriers to change and maintain new
behaviors over time (chapter eighteen)
overcome avoidance of intimacy through compassionate, flexible
exposure (chapter twenty)
increase satisfaction and deepen connection in relationships through
mindful appreciation of others (chapter twenty-seven)
handle the painful cognitions and emotions inevitable in all
relationships using dropping anchor, defusion, acceptance, self-
compassion, and self-as-context skills

And, in addition to all the above, there’s the choice point. As

illustrated below, we can use it to quickly map out any interpersonal
issue (attachment related or not).
 As with other issues, when using the choice point, we usually start
at the bottom: we identify a difficult interpersonal situation and the
thoughts, feelings, memories, or urges that show up. Then:
Therapist: What we want to do next is get a sense of what you
say and do when this stuff (pointing to the bottom)
shows up—and whether those things are towards
moves, that help build the sort of relationship you want,
or away moves, that make it worse.
Next, we look at the adaptive functions of the client’s problematic
interpersonal behaviors: how they have helped to protect the client or
meet their needs in various ways, both recently and in the past. (As
mentioned earlier, this is especially important when working with
complex trauma because these behaviors often started in childhood as
ways to survive abuse or neglect.)
Finally, we complete the towards arrow with new interpersonal
behaviors (values-based goals and actions) to help clients build the sorts
of relationships they want. The challenge formula often comes in handy
during this work.

The Challenge Formula

The challenge formula is useful for any type of relationship—with
partners, children, parents, friends, co-workers, and so on. The three
options are:
A. Leave the relationship.
B. Stay, and live by your values; do what you can to improve the
relationship while effectively handling the pain that’s inevitable.
C. Stay, and do things that don’t help or make it worse.
When we compassionately and respectfully present this formula,
most clients choose option b. However, sometimes they choose option a,
in which case, we help them leave the relationship, acting mindfully on
their values. Usually this warrants a lot of acceptance and self-
compassion, followed by work on grieving and forgiving (chapter thirty-
one). Of course, if the client is unwilling to leave, at least for the time
being, then b and c are the only alternatives.
Only rarely do clients choose option c. This almost always indicates
high experiential avoidance and fusion with hopelessness. In such cases,
we acknowledge and validate that choice and work on developing
TFACT skills (including lots of self-compassion) until the client has
enough psychological flexibility to choose option a or b.
But what if a client says, “I just don’t know whether to stay or
leave”? This is a sticky situation and, to address it effectively, I
recommend my worksheet for dilemmas (see Extra Bits). In the
meantime, until the dilemma is resolved, we can suggest, “So perhaps
one day you will decide to leave, but until that day comes, you are still in
the relationship. And every day you remain, you have two options: b or
c. So each morning, when you wake up, ask yourself: which option will I
choose for today? Or, if you can’t choose for an entire day, then just
choose for half a day, or even just for the next hour. Ask yourself, For
the next sixty minutes, which option do I choose? And when that time is
up, choose again.”
Note: obviously different strategies are necessary when the
relationship involves abuse or violence, but that’s beyond the scope of
this book.
 But It’s Not My Fault! They Need to
Change!
Some clients will initially react negatively to the idea of looking at
their own interpersonal behavior. They may say things like, “But it’s
him. He’s the problem, not me! Why should I have to change?” or “She
needs to change first. If she’d just stop doing XYZ, it’d be fine,” or
“They need to accept me the way I am!”
In such cases, we first validate their reactions, then explore the
issue of control. For example:
Therapist: You are right. Their behavior is creating problems
for you—and if they would just change their
behavior, it would be so much easier for you. So
would you be interested in learning how to make
that happen? (Client agrees.) Great, so we can’t
actually control other people, but we can influence
how they behave. And the way we do that is
through our own words and our actions.
Client: I’ve already tried that. Nothing works.
Therapist: That sounds very frustrating. I’d be feeling the
same way if I were in your shoes. However, it’s a
good place to start. Let’s recap everything you’ve
tried that hasn’t worked—so we can be sure to
look at some new strategies that you haven’t yet
tried.
Next, we return to workability. We elicit all the strategies the client
has used to try resolving the relationship issue(s). We validate and
normalize them, then encourage the client to look at them in terms of
their effects on the relationship: are they making it better or worse? Then
we summarize: “So you’ve worked hard at this relationship, and most of
the strategies you’ve used are extremely common—things we all tend to
say and do to try to influence others. And sometimes these things do
work, in the short term, to meet your needs—but long term, they’re not
building the relationship you want. Would you be open to trying
something different?”
If the client answers no, we can revisit the challenge formula and
clarify, with great compassion, “I totally get your reluctance to do that,
and I’ll certainly honor your wishes. I just want us both to be clear
though—what you’re choosing is option c: stay in the relationship and
do things that don’t help or make it worse.”
If the client answers yes to trying something different, the door is
now open to teaching new skills such as assertiveness, communication,
and negotiation. However, it’s important to explain, “These are
influencing skills. They are ways to influence the behavior of others, not
to control it. They hugely increase the chances of getting what you want
—or stopping what you don’t want—but they don’t guarantee it. They
are not magic, so there will be times they won’t achieve what you’re
hoping for, which is obviously upsetting. So another part of our work
here is learning how to handle the pain that shows up for you at those
times when these skills don’t give you what you want.”

Developing Relationship Skills

As a rule of thumb, the more complex and numerous the relationship
issues are, the greater the need for training in interpersonal skills. We
should be able to teach clients the following basic relationship skills:

Assertiveness—including how to say no, make requests, express

genuine opinions, and set boundaries
Effective communication—including words, facial expressions,
tone of voice, physical posture
Giving and receiving feedback—both positive and negative
Negotiating, compromising, and reciprocity
Conflict resolution—including how to apologize and make
reparations
 Developing empathy and compassion for others, to see things from
their point of view and imagine how they might think and feel
Reinforcing desired behavior when it occurs (e.g., through actively
noticing it and showing appreciation or gratitude)

Note that these are all basic therapy skills (hardly surprising, given
the central importance of building a strong relationship), so we should all
be somewhat familiar with them. Unfortunately, we don’t have room to
go through them here, but you’ll find them in my self-help book on ACT
for relationship issues, which is appropriately titled ACT with Love, and
also in the textbook Acceptance and Commitment Therapy for
Borderline Personality Disorder by Patricia Zurita Ona (2019).
Arguably the best way to develop these skills is through active role-
play in session. Initially the client plays the role of the other party, while
the therapist plays the role of the client and demonstrates the new skill.
They then swap roles: the therapist now plays the other party, while the
client plays themself and experiments with the new skill. The therapist
then gives feedback, the client reflects on what they discovered, and then
they try it again. And so on, and so on, until the client gets the hang of it.
And of course, learning new skills is challenging, so we help clients
bring in values for motivation, overcome HARD barriers, and practice
self-compassion when things go poorly.

Addressing Issues of Trust

If we have been badly hurt, threatened, betrayed, or abused by others,
often we find it hard to trust again. We easily fuse with the rule “Don’t
trust or you’ll get hurt!” The problem is, without trust, we can’t build
deep and meaningful relationships. So to help clients address this issue,
we can revisit the three strategies for rigid rule following (chapter
eleven):

1. defuse from the rule,

 2. discover the underlying values and explore flexible ways of living
them, and
3. make room for pain and be kind to yourself.

Let’s quickly run through these.

Defusion from the Rule “Don’t

Trust!”
Once again, we can turn to the strategy of notice, name, normalize,
purpose, workability. It’s usually easy to notice and name the rules
clients are fusing with: “I can’t trust XYZ, because if I do, bad things
will happen and I’ll get hurt.” We normalize such rules: we all have them
to various extents, and their purpose is to keep us safe. In terms of
workability, following such a rule has a big short-term payoff: it reduces
anxiety and fear of getting hurt, and it gives a sense of security and self-
protection. So we want to validate those benefits: “When the people
around you are dangerous or unreliable, following this rule keeps you
safe. In the past, it has protected you.”
We then compassionately explore the costs of rigidly following this
rule today: loneliness and isolation; lack of intimacy, connection, or
depth in close relationships; or ongoing conflict due to checking on,
interrogating, or disbelieving others. Sometimes this will lead to an
exchange like this:
Client: So are you telling me to just trust everyone?
Therapist: No. Not at all. That would be a recipe for getting
hurt, abused, and betrayed. I’m inviting you to
consider the possibility that maybe there’s another
way to use this rule. Rather than see it as a law
that you must always obey, no matter what, you
could see it as a piece of advice that’s useful to
follow strictly in some situations, but helpful to
bend in others.
 At this point, we usually need to do some psychoeducation on the
difference between “blind trust” and “mindful trust” (Harris, 2009b).

BLIND TRUST AND MINDFUL TRUST

“Blind trust” means trusting someone completely, without taking
the time to assess whether they are deserving of your trust or not.
“Mindful trust,” on the other hand, means carefully observing the
behavior of another person before deciding whether to trust them—and
continuing to observe carefully if and when we do start trusting. We may
encourage clients to look out for five factors:

Is this person considerate? (Do they consider and respect your

feelings, wishes, needs, and opinions?)
Is this person sincere? (Do they mean what they say?)
Is this person reliable? (Do they follow through on the things they
say they will do?)
Is this person responsible? (Do they consider the consequences of
their actions? If they make mistakes or disappoint, do they own up
to it, apologize, and atone?)
Is this person competent? (Are they able to do what they say they
will do?)

We can suggest clients get to know someone slowly; take their time.
Experiment with small actions of trust, carefully observing how the other
person behaves: do they tend to be considerate, sincere, reliable,
responsible, and competent?
Over time, they can experiment with larger acts of trusting (another
example of graded exposure) while continuing to carefully track the
consequences. Obviously, no one is perfect in all these five areas; at
times we are all lacking, but these qualities at least give some basis for
cautious trusting. And if there’s little or no sign of such qualities—that’s
a big red flag not to trust.
 Discover Underlying Values and
Flexibly Apply Them
Underneath the rule “Do not trust,” we usually find a value such as
self-protection. So we help clients flexibly act in self-protective ways
while also living their values of being trusting. We can draw a Venn
diagram with two overlapping circles, one labeled “trust,” the other
“self-protection.” In the outer area of one circle are behaviors that are
trusting but not self-protective; in the outer area of the other are
behaviors that are self-protective but not trusting. And in the overlapping
central area go behaviors both self-protective and trusting. We can then
explore when, where, how, and to what extent to draw upon behaviors
from that overlapping area, in the service of building meaningful
relationships. And again, graded exposure: small acts of trust initially,
building up gradually over time.
The fact is, any act of trusting involves some risk. If you want
absolute certainty that you will never get hurt in a significant
relationship, the only way to ensure that is to avoid significant
relationships. And if that’s what a client genuinely chooses, we would
respect that. However, so far I’ve never heard of a psychologically
flexible person choosing that option; when people say they’d rather be
alone than risk being hurt, that’s almost certainly fusion and avoidance
doing the talking. In such cases, we could work on building
psychological flexibility in other areas of life—then revisit relationships
later.

Make Room for Pain and Respond

with Kindness
Trusting again, after previous violations, will generate many
uncomfortable thoughts, feelings, and memories. So if close, meaningful
relationships are important to the client, are they willing to make room
for the inevitable pain involved? For all that anxiety and uncertainty? All
those fears of being hurt, betrayed, or disappointed?
 While we have a lot of control over the actions of trust, we have no
control over the feelings. Feelings of trust are hard to describe: a sense of
security, comfort, confidence, safety, and calmness. So if you’ve been
hurt or abused in previous significant relationships, feelings of trust will
be few and far between when you’re forming new ones, whereas feelings
of anxiety, doubt, insecurity, and vulnerability will be plentiful.
Over time, if the other person continues behaving in a trustworthy
manner, then maybe the feelings of trust will eventually arise. But this is
not something we can control. So, the two questions for our clients are
(1) in the service of building relationships, are you willing to make room
for these inevitable difficult thoughts and feelings? and (2) can you
acknowledge how painful and difficult and scary this is—and treat
yourself kindly?

EXTRA BIT In chapter twenty-eight you’ll find the “Attachment

Styles” handout and the “Difficult Dilemmas” worksheet.

Takeaway
TFACT is well-suited for any relationship issue, and attachment theory
is often a useful addition. While psychological flexibility helps build
better relationships (we get along better with others when we are present,
open, and living by our values), clients often need additional training in
interpersonal skills. Trust issues are common in clients with a history of
trauma, and an important part of our work is to distinguish blind trust
from mindful trust.
And, well done. You’ve made it to the end of part three of the book,
which covers the bulk of our work in TFACT: helping our clients live
meaningful lives in the present. In part four, we’ll focus on healing the
past, which, needless to say, is hugely important when working with
trauma.
 PART FOUR:

Healing the Past

 CHAPTER TWENTY-NINE.

Supporting the “Younger You”

Many adults initially find it hard to be compassionate to themselves as

they are today. They often find it easier to imagine being compassionate
to a childhood version of themselves. Thus, TFACT often uses “inner
child imagery and rescripting” as a pathway to self-compassion. In these
exercises, you revisit a painful childhood memory, and you imagine
yourself as the adult you are today going back in time to comfort and
soothe the “younger you”—the child you were back then. Your aim is to
empathize with, validate, and support the “younger you”; to be there in a
kind and protective way, and help them understand what was going on at
the time.

Practical Tip
Although I’m using it here, I recommend you don’t use the
phrase “inner child” with clients, for two good reasons. One, it’s
often associated with “new age” practices or nonscientific
models of therapy. Two, we often work with memories from
teenage or young adult years, as opposed to childhood.

Inner Child Imagery and Rescripting

In the big, wide world of TFACT, there are many variations on inner
child imagery and rescripting, so please modify the script below as
desired. To set these exercises up safely, make sure clients have good
dropping anchor skills (in case of adverse reactions) and practice graded
exposure: start with less challenging memories and gradually work up to
more difficult ones. Also, clearly establish that there is an “adult you”—
the person you are today—and a “younger you”—the child, teenager, or
younger adult you were back then, in the memory. (For ease, I’ll just use
the word “child” in the rest of the chapter.) Always have your client look
through the eyes of their adult self—and from that perspective, see the
child. This is so important. We don’t ask the client to imagine they are
the child, because that could easily plunge them into a world of fusion.
Keep the client identifying with the adult—always seeing the child
through the adult’s eyes.

Make It Interactive
We talk freely with our client throughout these exercises. We continually
check in and ask the client what the child is doing and saying, how the
child looks, how the child is responding. And the things the adult says to
the child should not slavishly follow the generic script below. Rather, we
help the client come up with their own words and gestures toward the
child. Some clients struggle to think of supportive, caring words or
actions—especially if they come from backgrounds where they
themselves never had such experiences. If so, we can be as directive as
necessary, actively coaching the adult in what to say and do to support
the child.
Clients often fuse with “It’s my fault” or “I should have stopped it,”
especially when dealing with childhood sexual abuse. During inner child
work, an alternative self-compassionate narrative often spontaneously
shows up; the client, without coaching from us, tells the child, “It wasn’t
your fault.” But if this doesn’t happen spontaneously, we prompt it: “Is
she still holding on tightly to ‘It’s my fault’? What is it like for that child
to go through life holding on to that judgment? Is there something you
might like to say or do to help her unhook?”
 If necessary, we then coach the client to speak and act
compassionately, to recognize and meet the physical, emotional, and
psychological needs of the child. For example, we may advise the adult
to pass on important bits of psychoeducation to the child: why they froze
up or why they experienced pleasure even though they hated what was
happening.
In the Compassion for the Younger You exercise, below, the
instructions basically involve asking the child if there’s anything they
need or want from you and providing it for them; offering your kindness,
compassion, and support; letting them know you’ll always be here to
help them; and giving them a gift of some sort. A sample script follows.

Compassion for the Younger You

You are about to do an exercise in imagination. Some people
imagine with vivid, colorful pictures, much like those on a TV screen;
others imagine with vague, fuzzy, unclear pictures; while others
imagine without using pictures at all, relying more on words and
ideas. However you imagine is just fine.
You’re going to imagine traveling back in time to visit a younger
version of yourself, at some point in your life when you were
struggling, and the people around you were for one reason or
another unable to give you the care and support you needed. This
could be when you were a child, or more recently as a teenager or
young adult.
Find a comfortable position and drop anchor: acknowledge
what’s going on in your inner world…connect with your body,
moving, stretching, breathing…engage in the world around you…
noticing what you can see and hear and smell and touch.
Now either close your eyes or fix them on a spot, and allow
yourself to imagine.
Imagine yourself getting into a time machine. I’m not going to
describe it—imagine it however you like: a portal, a bright light, a
mechanical apparatus, or just a vague sense of something you can’t
even see. And once inside it, imagine yourself traveling back in time
to visit your younger self. Find the “younger you” at some point in
their life when they are struggling—and the adults around them are
not providing the care and support they need.
Now step out of the time machine and establish contact with the
younger you. Take a good look at this child (or teenager or young
adult) and get a sense of what they are going through. Are they
crying? Are they angry or frightened? Are they feeling guilty or
ashamed? What does this young person really need: love, kindness,
understanding, forgiveness, acceptance?
In a kind, calm, and gentle voice, tell this younger you that you
know what has happened, that you know what they’ve been through,
that you know how much they are hurting.
Tell this younger you that they got through this difficult patch in
their life and it is now a distant memory.
Tell this younger you that you are here, that you know how much
this truly hurts and you want to help in any way you can.
Ask this young person if there’s anything they need or want from
you—and whatever they ask for, provide it. If they ask you to take
them somewhere special, go ahead and do it. Offer a hug, a kiss,
words of kindness, or a gift of some sort. This is an exercise in
imagination, so you can give them anything they want—even if in the
real world it would be impossible. If this younger you doesn’t know
what they want or doesn’t trust you, then let them know that’s fine;
they don’t need to say or do anything.
Tell this young person anything you think they need to hear to
help them understand what has happened—and to help them put an
end to self-blaming.
Tell them that you are here for them, that you care, and you’ll do
whatever you can to help them get through this.
Continue to radiate caring and kindness toward this younger you
in any way you can think of: through words, gestures, deeds—or if
you prefer, through magic or telepathy.
Once you have a sense that this younger you has accepted your
caring and kindness, it’s time to bid farewell. Give them a gift of
some sort to symbolize the connection between you. (The therapist
makes suggestions if the client is stuck—a toy or teddy bear for a
younger child; for someone older, perhaps an item of clothing, a
book, a magical object, or anything else that springs to mind.)
Say goodbye and let them know that you’ll come back to visit
again.
Then get in your time machine and come back to the present.
And now, let’s drop anchor…

Unpack the Exercise

When unpacking the exercise, we may ask:

What was that like; what did you get out of it or learn from it?
What words would you use to describe the way you treated the
“younger you”?
How can you apply this to your life today?
What can you say and do for yourself when you are hurting just like
that child was?

The idea with these questions is to translate self-compassion into

practical words and deeds the client can say or do throughout the day.
Many clients benefit from repeating this exercise as a homework task,
working with different memories.
EXTRA BIT Download Trauma-Focused ACT: The Extra Bits
from the “Free Resources” page on
http://www.ImLearningACT.com. In chapter twenty-eight you’ll
find a script for a “younger you” exercise (one version among
many).

Takeaway
“Younger you” exercises are an important tool in our armory against
shame, self-blame, and worthlessness. They are especially useful with
clients who initially resist self-compassion, because they often find it
easier to be compassionate toward a younger version of themselves.
 CHAPTER THIRTY.

Exposure to Memories

As mentioned earlier, we tend to leave formal exposure to traumatic

memories until late in therapy, for the simple reason that it’s often
unnecessary. In earlier sessions, there’s been plenty of informal exposure
to memories: noticing and naming them; acknowledging them while
dropping anchor; interacting with them through inner child work; and
responding to them with self-compassion. This, in combination with all
the other work on values, defusion, acceptance, self-as-context, and self-
soothing, is enough for many clients to get on with their lives and
respond flexibly when difficult memories arise.
However, if the client is still responding inflexibly to difficult
memories (i.e., getting hooked, doing away moves), then formal
exposure is warranted. But before we start, it’s essential for the client to
understand that the aim is not to reduce anxiety or eliminate the memory;
it’s to help them stay present and act effectively when these memories
surface, so they can live their values and pursue their goals. The Horror
Movie metaphor in chapter seven conveys this well. (And if clients are
fixated on eliminating memories, we return to creative hopelessness.)

Considerations for Formal Exposure

Before commencing formal exposure, there are a number of practicalities
to consider: how to ensure a safe experience for the client, how to
prepare ahead for the likelihood of fusion, and how to monitor responses
during the procedure. Let’s quickly take a look at each of these topics.

Setting Up Safely
Before beginning formal exposure, we check off every item on this
list:

1. You’ve established a clear, nonverbal safety signal.

2. The client has good dropping anchor skills.
3. The client has at least basic skills in defusion, acceptance, and
self-compassion.
4. The client can take the observer perspective (self-as-context).
5. Values-based goals are the motivation for exposure.
6. The client understands the purpose and intended outcomes.
7. The client has chosen a specific memory to work with.

Practical Tip
If the client has so many painful memories that they can’t settle
on one, we can list them all on a sheet of paper, flip a coin
above it, then work with whichever one the coin lands on.
Alternatively, we can write them all on small strips of paper, put
them into a bag, shuffle them around, and draw one out at
random.

Preempting the Mind and Writing

Thoughts Down
 Fusion is likely to arise during this process, especially with harsh
self-judgment and self-blame, so it’s often useful to revisit the strategies
of preempting the mind and writing thoughts down: “What unhelpful
things do you think your mind might say as we do this?” “Can we write
those thoughts down, so we’re ready for them if they show up?” Then,
when fusion arises, we can point to the written words: “There it is. We
guessed your mind was going to say that. So do we need to address this
—or can we carry on?” Usually, the client defuses rapidly and chooses to
continue.

Tracking Responses and Moving with

the TIMES
When all the above is in place, we can undertake exposure, as
described in chapter twenty, ensuring that we always keep the client
within their window of flexibility. We start and end each session with at
least one or two minutes of dropping anchor and use the three scales of
presence, willingness, and control over physical actions (CPA) to track
the client’s responses. Throughout exposure, we repeatedly connect
clients with their values; every few minutes we ask questions such as
“And what’s this work in the service of?” “And what values are you
living right now, as we do this?” “And take a moment to connect with
why you’re doing this challenging task.”
We also “move with the TIMES” (thoughts, images, memories,
emotions, sensations). So if an intense, overwhelming emotion shows
up, we shift focus from the memory to the emotion. Then, once the client
scores seven or above for presence, willingness, and CPA, we return to
the memory. Similarly, if clients fuse or dissociation seems imminent,
we drop anchor, defuse, and then return to the memory.

Case Example: Extract from a Session

with Beth
Beth is a forty-five-year-old ambulance driver and paramedic with two
young daughters. She is currently not working due to PTSD she
developed following her attendance at a car accident in which a baby and
a toddler died. All seven points on the checklist above have been
addressed.
Beth’s motivations for exposure are “loving, caring for, and being
present with my girls” and “going back to work, so I can get back to
helping and looking after people.” Beth has predicted that self-
judgmental thoughts are likely to arise: I’m pathetic, I should be over
this, I’m letting everyone down, I should be able to deal with this by
myself. She has written these on a piece of paper, which rests on the
couch beside her. The exchange below follows two minutes of dropping
anchor:
Therapist: So what’s showing up for you now?
Client: I’m really scared. I’m really terrified that you’re not
going to be able to help me.
Therapist: Yeah. So…do you notice that in your body
anywhere in particular?
Client: I feel…yeah. I feel kind of numb and weak.
Therapist: Where do you feel that most in your body right
now?
Client: You know I kind of feel something here. I don’t even
know what it is, but I just feel like I have no, no
movement in my body. No…no strength.
Therapist: Okay. So can I just ask you to drop anchor
again? Push your feet into the floor, sit up straight.
(Client does so.) And can I get you to just push
your fingertips really firmly together there? (Client
does so.) And see if you can feel that all the way
up your arms. Can you feel your elbows?
Client: Yeah.
 (Dropping anchor continues for another minute. Then the therapist
asks for scores on presence and CPA; Beth scores eight and nine.)
Therapist: So are you willing to have this anxiety, in order to
do something that matters?
Client: Yes.
Therapist: How much, zero to ten?
Client: Eight.
Therapist: Great. And as we continue, anytime you’re
getting overwhelmed, or locked up, or shutting
down, I’ll get you to run through this drill, okay?
Client: Okay.
Therapist: So I’m going to ask you to tell me about the
accident—but let’s not plunge right into the most
awful part of it. Let’s lead into it gradually. So
maybe start with you responding to the call. And
talk me through it as if it’s happening now. So
who’s driving the ambulance?
Client: Yep, I’m driving.
Therapist: Okay so you’re driving, and how do you hear
about the accident?
Client: Well, we heard the dispatcher, and we were closest
to the scene; I think we were ten minutes away—
so siren on.
(The client has slipped into speaking in the past tense—“we
were”—so the therapist now steers her to speak in the present tense
—“you are driving.” This is to keep the memory immediate, as if
happening now.)
Therapist: Okay, so you are driving, and you’re ten minutes
away. Can you tell me what you hear on the call,
 as if it’s happening now?
Client: Uh yeah, well they’re saying it’s an accident on the
interstate. Just routine. Doesn’t seem like a big
deal.
(For the next two minutes, the therapist elicits details about the
drive to the scene of the accident. Beth says the traffic conditions are
good. She describes her fellow paramedic, Dave, as reliable, with a good
sense of humor, and says they work together well. She says they are both
a bit annoyed because it’s near the end of the shift and they want to go
home. Suddenly Beth goes pale and tenses up.)
Therapist: What just happened?
Client: Blood.
Therapist: You saw blood? Okay—so your mind has pulled
you ahead—can we rewind the memory, back to
where you’re driving? Is that okay?
Client: Yep. Yep.
Therapist: Just push those feet into the floor. Push those
hands together. Just look around the room. It’s you
and me, working together, here and now. Are we
okay to keep going?
Client: (nodding) Yeah.
(Beth is very obviously moving, engaging, responsive, and willing
to continue, so the therapist doesn’t formally obtain scores for presence,
willingness, or CPA. For the next few minutes, the therapist “advances”
the memory—prompting Beth to describe how events unfolded, moment
by moment, with as much sensory detail as possible: what she can see,
hear, touch, and smell. Soon she reaches a more disturbing part of the
memory.)
Client: The traffic is backed up so we know it’s ahead. You
know, people are rubbernecking, slowing down.
 Um, and the truck, it’s kind of come across the
road, from the opposite side, right?
(Beth is now breathing rapidly, very tense, very pale. The therapist
helps her drop anchor, then checks scores: CPA eight, presence eight,
willingness seven.)
Therapist: So…okay to keep going?
Client: Yeah, yeah…I just. You know, I think of those kids on
the road and that they’re never going to…you
know… (tearing up, voice shaking)…and it makes
it really hard to even be with my girls.
Therapist: Yes, it’s horrific. It’s just…for me just hearing the
story from you…it’s horrifying.
Client: It is. It is. And I can’t even be with my kids without
thinking about this. I mean…
(The therapist now moves briefly into acceptance and self-
compassion: Beth notices and names her feelings and does a ninety-
second version of the Kind Hands exercise. Then the therapist asks for
more detail. Beth says it’s a large white truck, and it’s “corkscrewed on
itself.” Sixty feet in front of the truck, there’s an overturned green sedan,
lying upside down on its roof. The windows are smashed, a door is
open…)
Client: And I’m kind of coming toward it. I’m driving toward
it.
Therapist: So again, those feet on the floor, noticing your
breath, noticing you’re here with me and we’re
talking about a memory. And let’s bring in that
noticing and naming stuff. Can you say, I’m
noticing a memory of…
Client: I’m noticing a memory of…the truck and the sedan…
on the road.
 Therapist: Okay. And a quick check-in: what’s showing up
for you?
(Beth reports feeling “sick in the stomach,” “tightness in the
throat,” and a “sense of impending doom.” The therapist helps her
NAME and drop anchor.)
Therapist: Now just…how in control are you of your arms
and legs right now?
Client: I’m good. Nine.
Therapist: And you’re here with me—present?
Client: Yep. Nine.
Therapist: And the memory is here too?
Client: Yep.
Therapist: So there’s you and me here, working together,
with this memory. And I’m curious, what’s your
mind saying about all this—about what we’re
doing?
Client: The same old stuff. Why am I being so pathetic? I’ve
been trained for this. I should be able to suck it up,
get on with it.
Therapist: Yeah, it doesn’t stop that theme for long, does it?
(Therapist points to the list of self-judgmental
thoughts Beth wrote down earlier.) So do we need
to address that—or can you just let it chatter
away?
Client: It’s not too loud. We can leave it.
Therapist: Okay to carry on?
Client: Yeah.
 Over the next ten minutes, the same process is repeated. Prompted
by the therapist, Beth talks through the memory, moment by moment.
The ambulance screeches to a halt. Beth switches off the engine. The
siren stops. Dave gets out first, slams the door, runs off. A few seconds
later, Beth gets out from the other door. She runs to the overturned car.
Dave is there, ahead of her. There’s a mechanical smell—fumes, burned
rubber. Debris all over the road.
The therapist frequently pauses and asks Beth to pause and check
in: to notice what thoughts and feelings are showing up and give scores
for presence, willingness, and CPA. They segue into defusion,
acceptance, self-compassion, or dropping anchor as required—and once
the scores are seven or above, they continue advancing through the
memory.
When Beth reaches the worst part, where she first sees the dead
baby, she goes pale, hyperventilates, stops talking. Her presence score
drops to four and CPA to three, and it takes three minutes of dropping
anchor to get them back to seven. After this, the therapist introduces a
brief “values break.”

Taking Values Breaks

Exposure sessions typically go for twenty to forty minutes, but they
can be shorter or longer, and if at any point the client wants to stop,
that’s fine. If the client seems to be getting tired or overwhelmed or starts
to dissociate, we help them drop anchor and then take a quick “values
break,” to help them connect more deeply with the values-based goals
motivating this challenging work. Here’s the values break with Beth,
mentioned above:
Therapist: Just remind me about your kids. They’re ten and
seven, right?
Client: Yeah. Dawn and Sarah.
Therapist: Okay. And what are some of the cutest things
they do?
Client: Oh, like just you know…millions of things, every day.
You know in the last couple of weeks as well,
they’ve just been super helpful and you know, lots
of “I love you” and doing sweet little things. I mean
I’m so worried that they are being affected by this
you know, ’cause I’m kind of…I’m not there really
and they know it. (Tearing up.) Um…they know it…
Therapist: Are you getting pulled into that stuff again?
(Therapist points to the page of self-judgmental
thoughts.)
Client: Yeah. Yeah. Yeah.
Therapist: Just come back to telling me some of the cute
things that they do.
Client: So Sasha, my eldest, she loves baking and making
cupcakes and stuff like that.
Therapist: Yeah? What’s the most recent thing she’s made
you?
Client: Oh she makes little lemon tart things all the time.
She’s just super beautiful. She’s so kind, yeah.
Therapist: What are you feeling right now as you kind of
share this with me?
Client: Oh I just want to be with them. I just want to hug
them.
Therapist: So that’s a big part of what this work is about,
right? You and your kids…and being there for
them… Being loving and caring and present…
Client: Right.
Therapist: So can we carry on? Or you’ve had enough for
today?
 Client: We can carry on.

Checking In for Impulses to Move

During a check-in, in addition to noticing thoughts and feelings, and
scoring presence, willingness, and CPA, we can ask about urges or
impulses to move, stretch, or change position. These often show up at
various points, and if so, we can invite the client to mindfully follow
through on them. Here’s an example from about ten minutes into the
session with Beth:
Therapist: I’m wondering—as we do this work, sometimes
people feel the need to move in particular ways.
Are you feeling an urge to stretch or move in any
particular way?
Client: Yeah, do you mind if I sit—I want to sit differently.
(Beth lifts her legs and sits cross-legged on the
couch.)
Therapist: Crossed legs is better for you?
Client: I prefer that, yeah, I just…
Therapist: Is there a…you know, is there a particular stretch
you might like to do? Are you tensing up
anywhere?
Client: Yeah, I just feel this kind of neck thing.
Therapist: Do you want to do a bit of neck stretching?
Client: Yep. (Beth stretches her neck.)

Continuing the Session

The session with Beth continues for another fifteen minutes. Bit by
bit, she describes the rest of the memory—the severely injured mother,
the second dead child, the procedures she followed, and so on. And all
the while, the therapist helps her respond flexibly, from all three points
on the triflex, working with the core processes until her scores reach
seven or above. Next the therapist suggests summarizing the memory:
Therapist: So, is it okay if we go through that again, but a lot
faster this time? The idea is to see if you can distill it to
about sixty to ninety seconds, still covering all the main
points—but just like a brief summary. And the idea is to
talk it through, and see if you can stay present, and
allow your feelings, and from time to time, stretch or
move—make sure you’ve got control of your arms and
legs.
Beth follows the instructions. She talks through the memory from
start to end, and it takes about ninety seconds. The therapist is fully
prepared to intervene, but it isn’t necessary. Beth’s voice is shaky, but
she finds it easier to talk than the first time around, and is much less
distressed as she does so. At the end, her scores are all seven or above.
The therapist then asks her to do the same again. This time she
describes the memory in a calmer, more fluent voice, and it takes about
seventy-five seconds. At the end, her scores are all eight or above. The
therapist suggests this is a good place to stop, and Beth agrees. They
finish up with a two-minute combination of dropping anchor and self-
compassion.
The exposure session has taken just under thirty minutes, which
includes two minutes of dropping anchor at the start, and another two at
the end. This leaves ten minutes to debrief and discuss homework. For
homework, we generally recommend two things:

If this memory or a similar one appears, the client is to respond as

they practiced. They notice and name it, make room for their
thoughts and feelings, connect with their body, take control of their
actions, and engage in what they are doing.
 If the client has been avoiding important values-base activities in
order to avoid triggering this memory (or similar ones), they now
resume those activities (following an exposure hierarchy, if
desired).

Many Ways of Working with Memories

If you wish to use EMDR or prolonged exposure (PE) as an addition or
alternative to the TFACT procedures above, that’s fine; however,
tweaking is needed to ensure the models don’t clash. Most importantly,
keep the aim of exposure ACT-congruent: to enable flexible, effective,
values-based behavior in response to painful memories. Also, reduce the
emphasis on lowering anxiety or distress. This is especially important
when it comes to the SUDS. As you know, in TFACT we don’t use the
SUDS, but in both EMDR and PE it’s a central tool. So if you’re
bringing procedures from those models into a TFACT framework, and
you intend to keep using SUDS, you want to place much more
importance on scores for presence, willingness, and CPA than you do on
the SUDS. And when the SUDS drops, you might say, “Enjoy that when
it happens; it often does. But keep in mind, that’s a bonus—not the main
aim.” (If the client seems confused, revisit the values-based goals
motivating the exposure.) Another option is to drop the SUDS altogether
—just stick to scores for presence, willingness, and CPA.
Finally, the diagram below summarizes many ways we can work
with memories in TFACT—all of which involve exposure. We’ve
covered most of them in this book.
 Summary of Methods for Working with Memories

Takeaway
Formal, organized exposure to traumatic memories is often unnecessary.
But if and when it is necessary, we use the same core processes we
would with any other repertoire-narrowing stimuli. First, we help clients
drop anchor. Then we help them dance around the triflex—being present,
opening up, doing what matters—to broaden their window of flexibility.
 CHAPTER THIRTY-ONE.

Grieving and Forgiving

Trauma always involves significant loss. People may lose their loved
ones through death or separation; their physical health; their freedom or
independence; their sense of security or trust; their roles; their
community; their childhood; their basic rights to be loved, respected, and
cared for; and so much more. Given all these losses, it’s no surprise we
are often working with grief.

What Is Grief?
Many people talk about grief as if it is synonymous with sadness; but
grief is not an emotion. Grief is a psychological process of reacting to
any significant loss. During a grieving process, we may feel a wide range
of emotions, from sadness and anxiety to anger and guilt, as well as
physical reactions such as sleep disturbance, fatigue, lethargy, apathy,
and changes in appetite.

Stages of Grief
The famous “five stages of grief” are denial, anger, bargaining,
depression, and acceptance. When Elisabeth Kübler-Ross described
these stages, she was referring to death and dying, but they can apply to
any type of major loss. As Kübler-Ross often stated, there’s no fixed
order to these stages, and not everyone goes through them all. Nor are
they discrete and well-defined; rather they tend to ebb and flow and
blend into one another—and they often seem to end, then start again.
Although contemporary models of grief counseling no longer use
Kübler-Ross’s framework, the stages she described are very common,
and your clients are likely to experience at least some of them. And
because these stages are now so well-known, it’s good to be aware of
them, in case your clients wish to discuss them.
“Denial” means a refusal or inability to acknowledge the reality of
the situation: unwillingness to talk or think about it; trying to pretend it’s
not happening; a sense of being numb or “shut down”; or walking
around in a daze, feeling like it’s not real—it’s a bad dream.
“Anger” refers to anything from resentment and indignation to fury
and outrage, or a strong sense of unfairness or injustice. You might get
angry with yourself, or others, or life itself, and frequently this spills
over into blame.
“Bargaining” means that you are trying to strike deals to alter
reality. You might ask God for a reprieve or ask a surgeon to guarantee a
successful operation. Often there’s a whole lot of wishful thinking and
fantasizing about alternative realities: “If only this had happened”; “If
only I hadn’t done that.”
“Depression” has nothing to do with the clinical disorder of the
same name. This unfortunate choice of word refers to emotions such as
sadness, sorrow, fear, anxiety, and uncertainty: all normal, natural human
reactions to loss.
“Acceptance” means making peace with our new reality instead of
struggling with it or avoiding it. This frees us up to invest our energy in
gradually rebuilding our life.

Many Ways to Grieve

Probably one of the most useful things we can convey to clients is
that there is no “right way” to grieve. There are no “right things” to do;
no “right feelings” to have; no “right amount of time” to grieve for.
Everyone finds their own unique way of grieving, and that will be
hugely influenced by factors such as family history, cultural background,
and religious or spiritual affiliations.
There are ideas “out there” that you should feel this, or you
shouldn’t feel that; or you should cry, or you shouldn’t cry—and so on.
And the truth is there is no right or wrong way to feel when you’re
grieving. Some people feel angry. Others feel sad. Some feel guilty.
Others feel numb. Some people even feel relief. And as with all
emotions, they change like the weather: they rise and they fall; they
come and they go.
Everyone is free to grieve in their own way, to feel what they feel
and to grieve for as long or as short as they wish. One of the biggest
myths about grief is that if it goes on for too long, it’s pathological; that
there should be a certain duration to it, and beyond that, there’s
something wrong. But if you’re a parent and you’ve lost a young child,
it’s not uncommon to experience periods of grieving for the rest of your
life—on and off, at different times and places.

The Act of Grieving

TFACT lends itself beautifully to the grieving process. Initially, our
focus is on helping clients to drop anchor amid the huge waves of
emotional pain that hit them again and again, normalizing their pain as a
natural reaction to loss, and fostering acceptance and self-compassion.
Later, we explore values: What do they want to stand for in the face of
all this pain, tragedy, and suffering? How do they want to treat
themselves and others as they go through this?
And then we help them translate these values into action: adjusting
to their loss and rebuilding their lives, one small step at a time. This will
vary enormously from person to person. We need to explore: What is
workable for this unique client at this time? Do they need to slow down,
take time out from their daily routine—to rest and recuperate? Or do
they need to do the opposite: reengage in life, reach out to and connect
with others?
 The metaphor of “taking a stand” is often helpful:
Therapist: There’s a massive reality gap here; a huge
chasm between the reality you want and the reality
you’ve got. And most of us, at least initially—we
kind of get crushed by that reality gap; or we run
from it, hide from it, with, you know, all the usual
suspects: drugs, alcohol, distraction. But what
we’re talking about here is turning toward this
huge gaping hole—and standing for something.
And it’s totally up to you what you stand for—
whether that’s courage or honesty or compassion or
love or…you know, there’s no right or wrong…it’s just
about being who you want to be, in the face of this.
So, suppose I bump into you, five years from now,
and I ask you, “What did you stand for, back then,
five years ago, in the face of that huge reality gap?
How did you treat yourself and the people you love?”
What would you want to answer?

When we help clients to live their values in the face of a huge loss,
it empowers them. They discover they don’t have to give up on life; even
with its gaping holes, they can embrace it. And after they’ve reached that
point, we can help them to “find the treasure” (i.e., use their mindfulness
skills to notice, appreciate, and savor those moments or aspects of life
that are meaningful, enjoyable, or inspiring).
This is not about “positive thinking,” seeing “the glass as half full,”
finding the “silver lining in every cloud.” And it’s not about ignoring or
distracting from the pain. It’s about recognizing that in the midst of your
pain and suffering, there are aspects of life you can treasure. You can
savor that glass of cold water that quenches your thirst. You can
appreciate acts of kindness, caring, and support. You can step out and
marvel at the sunset. While this doesn’t alter the past or get rid of your
pain, it does help you connect with the richness and fullness of life in
this moment.
 Complicated Grief
Grief is a normal psychological process of coming to terms with a
loss, accepting it, and adjusting to and reengaging in life. “Complicated
grief” is a pathological process where normal grieving is interrupted by
cognitive fusion and experiential avoidance.
Clients may fuse with narratives such as “Life’s not worth living,”
“I can never get over this,” “It would be dishonorable of me to get on
with my life,” or “I don’t deserve to get over this; I’m such a bad
person.”
The other aspect of complicated grief is experiential avoidance. In a
typical grieving process, we expect painful emotions, and our aim in
TFACT is to open up and make room for them; allow them to come and
stay and go in their own good time. But if we’re high in experiential
avoidance and we’re not willing to have those painful feelings, then what
happens? Well, all the usual suspects: drugs, alcohol, social withdrawal,
interpersonal conflict—all the various strategies that humans use to fight
with or run from painful emotions.
So fusion and avoidance lead to unworkable action. And at times
this can result in seemingly contradictory patterns of behavior. For
example, after the death of their child, a parent may avoid anything or
anyone that reminds them of the loss, such as friends or family with
children of a similar age; yet at the same time, they may preserve the
child’s bedroom exactly as it was and spend large amounts of time in
there, reliving the past.
Basically, then, the greater the client’s fusion and experiential
avoidance, the more likely is complicated grief. And we target this with
all the core processes: defusion, acceptance, present moment, values,
committed action, self as context, and especially self-compassion. For
more on this topic, you may appreciate my self-help book on ACT for
grief and loss. In the UK, Australia, and New Zealand it’s called The
Reality Slap (2nd edition; Harris, 2020); in the US, it’s titled When Life
Hits Hard.
Resentment and Forgiving
Many clients get consumed by resentment: dwelling, with anger and
bitterness, on past events. There are several powerful metaphors that
relate to this. In Buddhism, they say resentment is like holding on to a
red-hot coal to throw it at somebody else. (A friend of mine, who works
with teenage boys, changed this to “Resentment is like holding a squishy
dog shit, to throw it at someone else.”) In Hinduism, they say resentment
is like burning down your house to get rid of a rat. And in Alcoholics
Anonymous, they say resentment is like swallowing poison and hoping
the other person dies.
These metaphors all convey the same message: you are the one
getting most hurt by resentment. Sure, from time to time, in the grip of it,
you may act out and hurt others; but you’re the one who’s getting hurt on
a daily basis. It may be that the events that happened to you are now
years or decades in the past. But in the grip of resentment, you
experience them over and over, each time painfully scolded by the
injustice and unfairness of the world. So it’s a painful and life-draining
process, which doesn’t alter the past or help you heal.
It’s often helpful to mention the origin of the word:
Therapist: Did you know the word “resentment” comes from
the French word ressentir, which means “to feel
again”?
Client: Err, no.
Therapist: (playfully) Well, don’t say you didn’t learn
anything in these sessions. (Client chuckles.) So
basically, your mind hooks you and drags you
back into the past—reliving all the old hurts and
wounds and the bad stuff—so you get to feel it,
over and over, getting angry about all the events
that happened. And of course, that’s completely
natural. We all do it. But the problem is, it sucks
the life out of you.
 Client: (sadly) Yeah. It does.
The antidote to resentment is forgiving. (I use the verb “forgiving”
rather the noun “forgiveness” because it’s an ongoing activity. At times,
we’re forgiving, and at other times, we aren’t.) Unfortunately, many
clients think forgiving means “letting them get away with it” or saying
what happened didn’t matter. So we explain:
Therapist: “Forgiving,” at least as we use the word in TFACT,
means giving yourself back what life was like before
resentment took over. So it’s something you do for
yourself. You don’t do it for anyone else; it’s just for
you. To give you peace of mind. And help you live a
better life, moving forward.
When working with our clients, or practicing this ourselves, the first
step in forgiving is getting present. Our minds try to pull us back into the
past. But life is happening here, right now. So it’s about unhooking
ourselves from all that past-oriented cognition and coming back to the
present. Dropping anchor (chapter eight) and Getting Out of the River
(chapter eleven) are both useful practices for this.
The next step is making room for that pain and practicing self-
compassion.
And the third step is returning to our values, asking ourselves,
“That was in the past; from here onward what do I want to be about?
What do I want to do with my time left on this planet? What sort of
future do I want to build?”
(Are you getting a sense of déjà vu, here? Because TFACT is
transdiagnostic, the same overarching processes—be present, open up,
do what matters—apply to just about every trauma-related issue we
encounter.)

Self-Forgiving
Have you ever beaten yourself up for doing something you now
regret? Or for not doing something you “should” have done? Ever gotten
hooked by “Why did I do that?” “Why didn’t I do that?” “How could I
have been so stupid?” “How could I have let that happen?”
Sure, you have. We all beat ourselves up over this stuff. But often
our clients take this to extremes of self-blame, self-criticism, and self-
hatred. They may blame and judge themselves for acts of violence, such
as shooting an innocent person in a war zone; or for doing destructive
things under the influence of drugs and alcohol; or for neglecting their
children; or for “freezing” instead of fighting; or a million and one other
things.
Self-forgiving is arguably a “subset” of self-compassion. It involves
defusing from harsh self-judgment, acknowledging how painful it is that
those things happened, and treating yourself with kindness and
understanding. And it’s important to connect with the values underneath
all that harsh self-judgment. We may say, “You know, the fact that your
mind is beating you up and giving you such a hard time over this…
What does that tell you about the sort of person you really want to be,
deep inside? What does that tell you really matters to you?”
For example, if a client is beating themself up over neglecting or
hurting their loved ones, that suggests values of being loving and caring.
And if they’re blaming themself because they didn’t report, stop, or
address something, that points to values of courage, assertiveness, and
justice. We may point out, “If you didn’t have those values, you
wouldn’t be giving yourself such a hard time about this.”

Forgiving Others
The TFACT take on forgiving is very liberating. You don’t have to
say or do anything to the other person—which is good, because they
may be dead, oblivious, or in denial; or you may not even know who
they are. And you don’t have to “let them get away with it”; with this
approach, you can practice forgiving yet still take the wrongdoer to court
and prosecute them.
Sometimes clients read self-help books that assert, “To recover
from your past, you must forgive those who hurt you.” But there is no
scientific validity to those claims. When it comes to trauma, it may be
impossible to forgive the people who have hurt, harmed, betrayed, or
abused you. So if a client says things like “I know I should forgive
them,” we help them defuse:
Therapist: Notice your mind laying down the law. This is your
life. It’s about what you want to do, not what your mind
says you should do. If it’s important to you to forgive
them, if that’s what matters deep in your heart—we can
work on that. But if you don’t want to or you’re not
ready to, that’s fine; you certainly don’t have to.
I think of forgiving others in terms of two different stages—the
second being significantly harder than the first. Let’s take a look at them.

STAGE ONE
The first stage in forgiving others is outlined in the worksheet
below (which you can find in Extra Bits).
 How to Forgive Others
When I get hooked by blame, judgment, or resentment toward the
person(s) who hurt me, and pulled into reliving what they did, the
effect that has on me is

At times, when hooked by those thoughts, feelings, and memories, I

have done things that made my life worse, such as

And what that has cost me is

So for my own health and well-being, I choose to practice unhooking

from blame, judgment, and resentment. The methods I will use are

And when difficult memories arise, I will acknowledge the pain and
be kind to myself, as follows:

I will also reflect regularly on the following:

What they did to hurt me. It gave rise to much pain and
suffering.
It was not okay. I will not forget it.
If I knew them inside out, knew their whole life history, I
would understand why they did this. But I will never
know for sure why they did what they did—and I don’t
need to.
 The fact is, we all screw up, make mistakes, and do
things that hurt others.
The fact is, we all at times get hooked by thoughts and
feelings and pulled into destructive patterns of
behavior.
The person(s) who did this is/are imperfect and fallible,
prone to human weakness and error—just as I am.
The person(s) who did this gets/get hooked by their
own thoughts and feelings and pulled into destructive
patterns of behavior—just as I do.
They did what they did, and I can’t change that, but I
can unhook from my judgments and my blaming and
practice self-compassion; and in the interest of
building a better life for myself, I will continue to do so.

STAGE TWO
Stage two involves communicating with the person(s) who hurt you
—in your imagination, rather than real life—letting them know that you
forgive them, and extending kindness toward them. This commonly
involves either visualization, meditation, or writing a letter (which you
don’t send). Loving-Kindness Meditation is a powerful way of doing this
work. If you read the full script in Extra Bits, you’ll see that the final
part of this practice involves thinking of someone who is a source of
suffering in your life, recognizing that they are a fallible human being
who hurts and suffers much like you, and sending out warmth and
kindness toward them. If you introduce this practice, I recommend
clients begin with some “less difficult people,” and over time, build up
their compassion muscles until they’re ready to attempt this with
someone who hurt them badly.
EXTRA BIT Download Trauma-Focused ACT: The Extra Bits
from the “Free Resources” page on
http://www.ImLearningACT.com. In chapter thirty-one, you’ll find
a script for Loving-Kindness Meditation and a worksheet on
forgiving.

Takeaway
Grieving and forgiving are important aspects of working with trauma, for
which we utilize all the core ACT processes. Grieving is a normal
psychological process of coming to terms with loss, but it becomes
complicated when fusion and experiential avoidance predominate.
Forgiving, in TFACT, means freeing yourself from the burden of
resentment. Self-compassion plays a central role in both grieving and
forgiving.
We’ve covered the first two interweaving strands of TFACT: living
in the present and healing the past. So you now have a solid foundation
of skills, strategies, and tools for treating clients with trauma-related
disorders. Next we’ll turn to the third strand of TFACT: building the
future.
 PART FIVE:

Building the Future

 CHAPTER THIRTY-TWO.

The Path Ahead

While the main emphasis of ACT is living in the here and now—acting
on our values and mindfully engaging in what we do—throughout
therapy, we repeatedly look to the future. This begins on the very first
session, when we ask questions like “What will you be doing differently
if our work is successful?” And it continues every time we help clients to
set goals, create action plans, anticipate obstacles, prepare contingency
plans, or ask questions like “Will that take you toward or away from the
life you want?”
So although I’ve placed “Building the Future” as the final section of
the book, it’s by no means the final stage in therapy. Forward thinking,
looking ahead, and planning for the future come into every session—
even if only to agree upon homework tasks for the forthcoming week.
However, as we near the end of therapy, “building the future” tends to
take center stage: sessions increasingly focus on goal setting, action
planning, problem solving, anticipating obstacles, overcoming barriers,
maintaining motivation, and sustaining new behaviors. So let’s do a
quick review of all these topics, and then we’ll look at posttraumatic
growth.

Values, Goals, Actions, and Obstacles

Throughout therapy, we encourage clients to develop the skill of goal
setting, which we hope they’ll actively use for the rest of their lives. And
the more challenging the goal is, the greater the need to chunk it into
easier, smaller goals—which are ideally SMART: Specific, Motivated by
values, Adaptive, Realistic, Time-framed. We follow this with action
planning: What actions are needed to achieve this goal? And what’s plan
B, if plan A fails?
The HARD barriers—Hooked, Avoiding discomfort, Remoteness
from values, and Doubtful goals—are likely to arise repeatedly, so we
help clients prepare for them: get them ready to unhook, open up,
connect with their values, and set SMART goals, as needed. Useful
questions include:

How’s your mind going to try to talk you out of this? How will you
unhook from that?
What difficult thoughts and feelings are likely show up? How will
you make room for them?
What can motivate you to persist?

The Willingness and Action Plan (see Extra Bits) brings all the
above elements together, so it’s particularly useful in later sessions.

Maintaining Change and Handling

Setbacks
As Mark Twain said, “Habit is habit, and not to be flung out of the
window by any man, but coaxed downstairs a step at a time.” We all
know how easy it is to fall back into old ways, so we can encourage
clients to use the Seven Rs: Reminders, Records, Rewards, Routines,
Relationships, Reflection, and Restructuring the environment.
In addition, we can help clients defuse from perfectionistic ideas
and unrealistic expectations. We all go offtrack at times, no matter how
much therapy or personal development we do. This is just as true for
practitioners as for clients—an aspect of our common humanity. At
times we will give up on our goals, lose touch with our values, or fall
back into old self-defeating patterns of behavior—and we will hurt and
suffer when that happens. Our default setting at these times is to pull out
a big stick and start beating ourselves up. But if beating ourselves up
were a good way to change behavior, wouldn’t we be perfect by now?
So we help our clients expect and prepare for these setbacks: to
drop anchor, acknowledge their pain, and respond with kindness; then
come back to their values and start again. We will all need to do this
many thousands of times, for the rest of our lives. (As I say to clients,
“We get to improve our behavior, but we don’t get to be perfect.”)

Specific Plans: Safety, Relapse

Prevention, and Crisis Coping
It’s often useful to plan ahead for recurrences of problematic behavior, to
predict what might trigger it and prepare a contingency plan, such as a
safety plan for suicidality, a relapse-prevention plan for addiction, or a
crisis-coping plan for stressful events. For this, the choice point comes in
very handy, as illustrated on the next page.
 Safety, Relapse Prevention, and Crisis-Coping Plan

At the top of the sheet we write in names and contact numbers of

professional sources of help (e.g., doctor, therapist, hospital, crisis line,
support service) and names and contact numbers of friends, family, and
others (e.g., a neighbor or sponsor) whom the client can talk to or ask for
help.
At the bottom of the choice point, we write in likely antecedents for
suicidality (or relapse or crisis). This includes situations, cognitions,
emotions, memories, sensations, and urges.
On the away arrow we write in problematic behaviors (both overt
and covert) to look out for. For example, in a typical safety plan, away
moves might include suicidal ideation, suicide threats, suicide planning,
and suicide attempts. In a relapse-prevention plan, the away moves
would be the addictive behaviors in question (e.g., taking drugs,
drinking, gambling) or ideation about doing them.
On the towards arrow, there are four sections. At the very bottom:
HELPERS (often called “reasons to live” in safety plans, or “reasons to
abstain” in relapse prevention). Here we write in values and values-
congruent goals; important people, activities, and domains of life; and
important beliefs or ideas that motivate towards moves.
In the middle: SKILLS. Here we write in useful mindfulness skills
(e.g., defusion, acceptance), self-compassion skills (e.g., kind self-talk,
kind self-touch), and self-care skills (e.g., self-soothing, assertiveness,
problem solving). And as therapy progresses, we add in the new skills
developed.
Near the top: SAFE ENVIRONMENT. Here we document what to
bring into or remove from the environment to make it safer. For
example, a client may remove drugs, alcohol, guns, or poisons, or bring
in a friend, a pet, or self-help resources such as books and recordings.
Sometimes the client will need to leave the environment—in which case
we specify safer environments to move to.
At the top: EMERGENCY. Here we write emergency contacts, in
case all else fails: names, numbers, and locations (e.g., crisis line,
hospital emergency department, or a reliable support person).

Anticipating Further Trauma

Some clients are at risk of exposure to further traumatic events, either
through their employment (e.g., emergency services), or because they are
in difficult situations they can’t simply leave (e.g., prison), or due to
ongoing systemic problems like racism. In such cases, we revisit the
challenge formula.
Option one is to leave. If the client can leave the difficult situation
(e.g., by changing career), we help them explore the pros and cons, after
which they may choose to leave.
If the client can’t or won’t leave the situation, then we help them
implement option two: live by your values, do whatever you can to
improve things, and make room for the pain that’s inevitable. This
includes actively reaching out to supportive others and using all their
TFACT skills—especially self-compassion—to take care of themselves
as best as they can in such difficult circumstances.

Ending Therapy
Our final session with a client usually focuses heavily on building the
future, including much of the content above. We recap the three
overarching TFACT skills—be present, open up, do what matters—and
we explore: How will the client apply these skills going forward? What
areas of life do they intend to explore and expand? What long-term goals
are they aiming for?
And we again want to highlight the inevitable recurrence of HARD
barriers, and ensure clients are adequately prepared to handle them.
(Remember, “forewarned is forearmed.”)
We also explore reactions to ending therapy. These vary
enormously, and the entire range of emotions may arise—in ourselves as
well as in our clients. Whatever a client’s reaction, we want to normalize
and validate it (our own, too), bringing in acceptance, self-compassion,
and defusion as required. Self-doubt and feelings of anxiety are
incredibly common—“I might relapse,” “I don’t know if I can keep it
up,” “I’m scared of doing it alone.” So yet again, we reframe this as
“your mind and body trying to protect you.” And of course, we let
clients know that if they ever want to return, the door is open.

Posttraumatic Growth
Psychologists Richard Tedeschi and Lawrence Calhoun (1996)
popularized the term “posttraumatic growth.” They interviewed
survivors of trauma to see what sort of long-term outcomes they had, and
they discovered, to their surprise, that many people went on to develop
and grow in positive, life-enhancing ways.
 For example, many survivors developed a much greater
appreciation for life. Prior to their trauma, they were taking life for
granted, but afterward, they started to truly appreciate and be grateful for
the opportunities life afforded them. Many also reported changes in their
sense of priority. They were more attuned to what was important and
meaningful. They gave priority to people they loved and activities that
fulfilled them—rather than all that “time-wasting stuff” that easily fills
up our lives.
Many reported developing warmer, closer relationships. They were
better at empathizing; better at having deeper, more intimate
connections. And many developed a greater sense of personal strength,
more courage or self-confidence, new life directions, and new paths for
spiritual growth.
Posttraumatic growth is different from “resilience,” which means
bouncing back to your previous point—back to where you were before
the trauma happened. Posttraumatic growth goes way beyond that. It
involves profound personal development and an increased ability to
actively create and appreciate a meaningful, fulfilling life. While some
clients spontaneously report these changes, often we need to gently
prompt them. Useful questions include:

What has been most meaningful or valuable to you in the work

we’ve done here?
Which new skills have been most useful?
What are the most positive changes you’ve noticed in how you do
things?
How have you grown or developed?
What differences have you noticed in your relationships?

Of course, we don’t have to leave such discussions to the end of

therapy—but if we haven’t already explored them, we definitely want to
do so in the final session.
 EXTRA BIT Download Trauma-Focused ACT: The Extra Bits
from the “Free Resources” page on
http://www.ImLearningACT.com. In chapter thirty-two, you’ll find
(a) a printable Relapse-Prevention Plan and (b) the Willingness
and Action Plan.

Takeaway
We can’t know for sure what the future holds, but we can to some extent
predict it, prepare for it, and influence it through the actions we take in
the present. So throughout therapy, we encourage clients to “build the
future” through a variety of methods, from goal setting and action
planning to preparing for obstacles and setbacks.
With TFACT, we’re hoping to help clients not just recover, but
experience posttraumatic growth. Obviously, this won’t happen with
everyone; to expect that is unrealistic. But it’s an outcome well worth
aiming for.
 CHAPTER THIRTY-THREE.

TFACT as a Brief Intervention

Most clients end therapy quickly. For example, in one eye-opening study
from 2005, researchers tracked data from 9,600 clients and found that
85% ended treatment by the fifth session (Brown & Jones, 2005). The
same study showed that the most common number of sessions a client
had (i.e., the “modal number”) was…just one!
This is just one example from a large body of research that shows
around 30 to 40% of clients end therapy quickly, without consulting their
therapist, and most average only four to six sessions. (For sure, some
clients do prefer long-term therapy—but they are a small minority.)
Aside from these sobering statistics, the fact is, our clients are suffering,
and they want relief. So the sooner we can provide it, the better. Hence
our challenge: How can we optimize client outcomes in as short a time
frame as possible? How can we help them reduce their suffering and
build meaningful lives—before they drop out of therapy?
For in-depth answers to these questions, I recommend you
investigate “focused acceptance and commitment therapy,” better known
as FACT: a brief intervention model pioneered by Kirk Strosahl and
Patricia Robinson. (Start with their excellent textbook, coauthored with
Thomas Gustavsson: Brief Interventions for Radical Change [Strosahl et
al., 2012].) FACT is useful for anyone who wishes to do ACT more
efficiently—especially practitioners in time-limited settings, such as
primary care, short inpatient stays, school or university counseling,
prisons, employee assistance programs, and crisis intervention services. I
won’t attempt to cover the whole FACT model in this chapter, but I will
draw from it to give you some ideas.

The Brief Intervention Mindset

When doing TFACT as a brief intervention, we start from the
assumption that rapid change is possible—even for clients with long-
standing problems. This is a pragmatic assumption; if it turns out to be
wrong—well, at least we tried. But if we start from the opposite
assumption, that rapid change is not possible—and because of this, we
move much more slowly than we need to, and therefore the client drops
out of therapy before developing any practical skills—then clearly we’ve
done them a disservice.

The First Session

A key assumption is that the first session is the most important—because
for a significant number of clients, it will be the only one they have. The
FACT mantra goes, “Assume one session, hope for six.” In other words,
when we see this new client for the first time, we hope they’ll return for
at least six sessions, but we are prepared for the possibility they won’t.
Working from this assumption, we don’t use the entire first session
for assessment; we need to free up time for active intervention. In each
session (including the first) we aim to do at least one brief intervention
from at least one point on the triflex: something that helps the client
develop a core TFACT skill, which they can immediately take away,
practice, and utilize. And if the client returns for a second session, we
can then complete the assessment (if we really need to). We would make
this explicit as part of informed consent:
Therapist: The idea here is that we work together as a team. We
have about thirty minutes in total, and we really want to
use that time effectively, to do something practical, like
 develop a new skill or strategy that you can take away
and use.
We know the client has come to see us—a huge act of trust—
because they want our help, so we don’t spend several sessions “building
rapport” before starting active intervention. We assume rapport is
already there, and the alliance will strengthen as we help the client
develop TFACT skills.

What Can We Do in Just Ten Minutes?

Get into the habit of asking yourself, What practical skill can my client
learn in this session, to take home and use straight away? Here are some
things we can do in under ten minutes:

Teach dropping anchor

Clarify some values (e.g., connect and reflect)
Set a goal and create an action plan (e.g., the bull’s eye)
Teach a defusion skill (e.g., I’m having the thought that…)
Teach an acceptance skill (e.g., physicalizing an emotion)
Teach a self-compassion skill (e.g., kind hands)
Teach a self-as-context skill (e.g., leaves on a stream)

With a bit of creativity, you can do almost every exercise, skill, or

practice in this book within five to ten minutes. So for a thirty-minute
session, allocate at least ten minutes to experiential exercises or skills
training. (But for a fifty-minute session, allocate at least twenty minutes
for this.)
The idea is to give clients one “piece” of the model on each visit.
For example, on session one, we might just give them dropping anchor;
on session two, some defusion; session three, some values, and so on.
Think of a domino effect: a small change in a positive direction can have
powerful ripple effects in other areas, and a versatile skill like dropping
anchor can be usefully applied to many different problems.

How Do We Find Ten Minutes?

To ensure we have at least ten minutes, we need to (a) focus on one
specific problem and (b) shorten other things that eat up therapy time.
To focus on a specific problem, we may say, “Could you pick just
one main problem or issue for today’s session? I know there are many,
but if we try to cover them all, we’ll run out of time without achieving
anything useful. So let’s focus on one, and once you have a strategy and
a skill that you can use to deal with it better, if there’s time, we can move
on to another.”
To shorten other things that eat up therapy time, consider these
options:

Cut back on psychoeducation.

Keep metaphors brief, and use them sparingly.
Reduce time spent “talking about ACT”—describing ACT
processes and how they can theoretically help—and instead,
actively practice new skills in session.
Create a Brief Intervention Toolkit you can easily dip into (see
Extra Bits).
Shorten creative hopelessness (see Extra Bits).
Make your initial assessment shorter. Consider: do you really need
all that information?
Take less history. Practitioners often gather a huge amount of
information that plays little or no role in terms of intervention.

But My Clients Want to Talk!

Our clients, just like us, want to be seen, heard, understood, validated.
Thus, in many models, the idea is that the client talks in depth and at
length about their trauma, while the therapist listens compassionately
and validates their feelings. This is often called “processing the trauma.”
In a brief intervention approach, we attend mindfully and bear
witness compassionately—seeing our clients as rainbows, not roadblocks
—and we do a whole lot more. When we are truly present and
compassionate, most clients feel heard, understood, and validated quite
quickly; it doesn’t take an entire session. And we continue holding that
Rogerian stance even as we move into building skills.
So if a client wants to keep talking, but we haven’t yet introduced a
practical skill they’ll be able to take home and apply, and we are now
running out of time—then for the benefit of the client, we need to take
the reins and get the session on track. (And uncomfortable though this
may be, if we don’t do it, we’re doing our client a disservice.) I’ve
experimented with different ways of doing this and found the following
five-step formula works well, as long as it’s delivered with genuine
compassion and respect:

1. We first validate the client’s suffering.

2. Then we say, “I would like to know more, but we have limited
time…”
3. Then we apologize: “I’m sorry if this seems rude…”
4. Then we ask permission: “Given our limited time, would it be
okay if we moved on to something practical…”
5. We give a rationale: “…because I really want you to leave here
today with something useful—a skill/technique/strategy that you
can use after the session, to help deal with this.”

For example:
Therapist: What you’re going through is really tough, really
difficult…and I hate to interrupt, but is it okay if I press
pause for a moment? My mind’s telling me that you’ll
think I’m rude or uncaring and you’ll be upset with
 me… But I notice we only have ten minutes left of our
session… And I’d really like to use that remaining time
to do something practical, to help you to deal with all
these painful memories and feelings. So is it okay if we
switch modes?

EXTRA BIT Download Trauma-Focused ACT: The Extra Bits

from the “Free Resources” page on
http://www.ImLearningACT.com. In chapter thirty-three, you’ll
find (a) How to Do Creative Hopelessness Briefly and (b) How to
Create a Brief Intervention Toolkit.

Takeaway
TFACT is very suitable for brief therapy with trauma. The key is to think
in terms of simple, easy-to-teach skills that we can run through in ten
minutes or less. If we can introduce a client to even one TFACT skill in a
session—and encourage them to take it away and practice it—we’re
doing something useful.
 CHAPTER THIRTY-FOUR.

Parting Words

So here we are in the final chapter, and what a journey it’s been. (At least
it has for me; hope it has for you too.) We’ll finish off with a few parting
comments and an inspiring poem.

Failure Is Inevitable
Here’s my guarantee: as you practice TFACT, you’re going to experience
failure. There will be clients who don’t react the way you expected or
hoped they would, techniques that fail or backfire, and sessions where
everything you try just doesn’t work. And of course, this isn’t just
TFACT; it’s true for every model of therapy. No model works for
everyone. Whatever approach you use, some clients will love it, and
some will hate it, and most will be somewhere in between.
And here’s another guarantee: you’ll make lots of mistakes. (If I
were to type out transcripts of all the mistakes I’ve made doing TFACT,
the resulting book would be several times the size of this one.) And
making mistakes is painful. But they hurt a whole lot more when our
harsh, judgmental minds start playing the “I’m a lousy therapist” theme:
I can’t do this, That was a disaster, I suck, This bloody TFACT stuff
doesn’t work! and so on.
We can’t stop our minds from saying these things, but we can
notice, name, and unhook from the “lousy therapist” theme, make room
for our painful feelings, and be kind to ourselves. And we can
acknowledge that our work is challenging; that it’s impossible to have
good outcomes with every client; that there’s no such thing as a perfect
practitioner, and at times we will all make mistakes.
We can then reflect on the session and reframe it as “a learning
experience.” After all, no matter what happened, no matter how badly it
went, there’s always something we can learn from it. Where did we get
stuck? Did we ourselves become fused or avoidant in session? Did we
omit parts of the model? Did we get so focused on technique that we
forgot about the therapeutic relationship? Did we hold back, go too slow,
when the client was ready to move forward? Did our own fusion or
avoidance stop us from doing the necessary exposure or other
challenging experiential work? Or did we perhaps move too quickly,
when the client wasn’t ready?
It’s also important to consider: Were there any moments in the
session—even if fleeting—where the client did respond flexibly? Any
moments where they were present, open, or doing what matters? If so,
what was different in those moments?
More simply, we ask ourselves three questions:

What worked?
What didn’t work?
What could we do more of, less of, or differently next time around?

Self-Care
Working with trauma is often stressful, and many therapists at times
suffer from vicarious trauma, compassion fatigue, moral injury, or
burnout. So it’s important that we apply ACT to ourselves: defusing
from unhelpful thoughts, making room for painful emotions, and holding
ourselves kindly; living our values both at work and outside it; investing
in our relationships; and looking after our physical health through
exercise, nutrition, leisure, and sleep.
 Of course, it’s much easier to say all that than to do it. But here’s
one practical tip that can really help: create your own ultra-brief self-
compassion ritual—even if it’s just one minute long—that you do after
every client. For example, at the end of a session, after the client has left,
you could take one minute to drop anchor, acknowledge your thoughts
and feelings, place a kind hand over your heart, and say something
supportive to yourself. Also try a longer version at the very end of your
work day; you can use this as a “transition ritual” to help leave work
behind and return to your home with a fresh mindset.

The Joy and the Sorrow

At times our work is fulfilling, inspiring, and uplifting. And at other
times it is distressing and disheartening. We don’t get the highs without
the lows. When we care deeply about our clients, naturally we
experience joy when we can help them—and sorrow when we can’t.
Because of this, I always end my TFACT workshops by reading a poem
from The Prophet, by Kahlil Gibran, and I’ve decided to end this
textbook the same way. This poem, “Joy and Sorrow,” is often read
aloud at funerals because it cuts right to the heart of the human
condition. So, leaving you with the wise words below, I’ll say farewell
and wish you all the best for your ongoing journey with TFACT.
Joy and Sorrow
Your joy is your sorrow unmasked.
And the selfsame well from which your laughter rises was
oftentimes filled with your tears.
And how else can it be?
The deeper that sorrow carves into your being, the more joy you
can contain.
Is not the cup that holds your wine the very cup that was burned in
the potter’s oven?
And is not the lute that soothes your spirit, the very wood that was
hollowed with knives?
When you are joyous, look deep into your heart and you shall find
it is only that which has given you sorrow that is giving you joy.
When you are sorrowful look again in your heart, and you shall see
that in truth you are weeping for that which has been your delight.
Some of you say, “Joy is greater than sorrow,” and others say,
“Nay, sorrow is the greater.”
But I say unto you, they are inseparable.
Together they come, and when one sits alone with you at your
board, remember that the other is asleep upon your bed.
 ACKNOWLEDGMENTS

First and foremost, several Olympic-size swimming pools of gratitude

for my beloved Natasha, for all her love and support and advice and
ideas, and for cheering me on during the many times I wanted to give up
(as well as giving me multiple life-saving doses of salted caramel Lindt
chocolate at all the right times).
Also, as usual, a bazillion buckets of deepest gratitude to Steve
Hayes, the originator of ACT—and to his co-creators, Kelly Wilson and
Kirk Strosahl. All three have been endless sources of knowledge and
inspiration. And along with that, many thanks to Sonja Batten, Robyn
Walser, Patricia Robinson, and Victoria Follette, pioneers of ACT with
trauma, and John Forsyth, Georg Eifert, and Mike Twohig, pioneers of
ACT with anxiety disorders; I have learned so much from all of them.
I am also very thankful to the larger ACT community; many ideas
within these pages have developed from discussions in the ACT Made
Simple Facebook group, the ACBS email list, and the forums of my
online courses. And I’m particularly grateful to Patricia Zurita Ona, who
strongly encouraged me to write this book when I kept hesitating, and
Claudette Foley, who reminded me of some really important aspects of
this work.
Next, many mega-doses of thanks to the entire team at New
Harbinger—including Catherine Meyer, Matt McKay, Clancy Drake,
Erin Anderson, Analis Souza, Karen Hathaway, Lisa Gunther, Leyza
Yardley, Cassie Stossel, Michele Waters, Madison Davis, Vicraj Gill,
Amy Shoup, and Caleb Beckwith—for all the hard work, care, and
attention they have invested in this book.
Editors are always the unsung heroes of successful books, so here’s
my loud chorus of appreciation to the heroic editorial efforts of Rona
Bernstein (whom I was delighted to work with again after her brilliant
work on the second edition of ACT Made Simple).
And last but definitely not least, a gargantuan grail of gratitude to
Michael Brekelmans, for his continual support and encouragement to
move in new directions, and his huge help and influence in creating new
and better training materials.
 APPENDIX A.

Resources

Free Resources
In addition to Trauma-Focused ACT: The Extra Bits, there’s a huge
treasure trove of free materials—including audio recordings, e-books,
handouts and worksheets, YouTube videos, book chapters, articles,
blogs, and published studies—available on the “Free Resources” page of
http://www.ImLearningACT.com. There, you can also sign up for my
quarterly newsletter, where I distribute new free resources as I create
them.

Books by Russ Harris

ACT Made Simple, 2nd edition (New Harbinger, 2019)
The world’s best-selling textbook on ACT, with over 100,000
copies sold, and translations into 20 languages. A classic in the field of
psychotherapy literature. (The second edition has over 50% new
material.)

The Happiness Trap (Exisle Publishing, 2007)

The world’s best-selling self-help book on ACT, aimed at everyone
and anyone. Over one million copies sold, and published in 30
languages.
The Illustrated Happiness Trap—by Russ Harris and Bev Aisbett
(Shambhala Publications, 2014)
A fun, comic-book version of the original—especially for teenagers
and adults who are not into reading. (It’s alternatively titled The
Happiness Trap Pocketbook in the UK and Australia.)

The Reality Slap, 2nd edition (Exisle Publishing, 2020)

An ACT-based self-help book for grief, loss, and crisis, with a
major emphasis on self-compassion. (The second edition has more than
50% new material.)

When Life Hits Hard (New Harbinger, 2021)

This is the same book as The Reality Slap (second edition),
mentioned above. Because it has over 50% new material, the US
publishers decided to change the title and release it as a new book.

The Confidence Gap (Exisle Publishing, 2011)

A self-help book that looks at confidence, success, and performance
from an ACT perspective; especially suitable for life coaching, executive
coaching, and sports and business performance.

ACT with Love (New Harbinger, 2009)

A popular self-help book on the use of ACT for common
relationship issues. (By the way, you may have noticed my other three
self-help books all have rhyming titles—The Happiness Trap, The
Reality Slap, The Confidence Gap—but this one doesn’t. I wanted to call
it The Relationship Crap, but the publishers wouldn’t let me.)

Getting Unstuck in ACT (New Harbinger, 2013)

The first advanced-level textbook on ACT. This does not cover the
basics; it assumes you know them. Instead, it focuses on common
sticking points for both clients and therapists.

ACT Questions & Answers (New Harbinger, 2018)

 Also known as “Everything you wanted to know about ACT but
were afraid to ask!” This is another advanced-level textbook, in an easy-
to-read Q&A format. It covers all those tricky, sticky questions about
problems not covered in most textbooks.

The Weight Escape—by Joe Ciarrochi, Ann Bailey, and Russ Harris
(Shambhala Publications, 2014)
A self-help book on the ACT approach to fitness, weight loss, and
self-acceptance with any size body.

Online Training—Public and

Professional
In case you don’t make it to appendix B, I want to mention this here: I
have created a range of online training courses in ACT, from beginner to
advanced level, covering everything from trauma, depression, and
anxiety disorders to adolescents, grief and loss, and brief interventions.
They are available at http://www.ImLearningACT.com. And if you
would like to go further with TFACT, this is the course to choose:

Trauma-Focused ACT: Online

Training
This advanced-level course—which includes many videos of
therapy sessions—is intensely practical, with a strong emphasis on skills
development. You’ll discover a treasure trove of methods to increase
your knowledge and skill level with TFACT, so you can help your clients
rapidly progress to posttraumatic growth.
 The Happiness Trap Online: 8-Week
Program
This is a personal-growth program for well-being and vitality,
inspired by and adapted from the book The Happiness Trap. It’s a
beautifully filmed and very entertaining online course, developed for the
general public—suitable for pretty much everyone. We’ve also designed
a version of the program that therapists can use with clients as an adjunct
to their therapy sessions. Find out more at
http://www.TheHappinessTrap.com.

MP3s
I have three albums of MP3s that you can purchase from
https://www.actmindfully.com.au: Mindfulness Skills Volume 1,
Mindfulness Skills Volume 2, and Exercises and Meditations from The
Reality Slap.

ACT Companion: Smartphone App

Australian psychologist Anthony Berrick created this excellent app for
use as an adjunct to therapy. It’s loaded with cool ACT tools, including
the choice point, and contains over two hours of audio recordings—some
with my voice, some with Anthony’s.

Values Cards
I’ve created a pack of full-color values cards containing simple
descriptions of values accompanied by delightful cartoons. More
specifically, they’re “values, goals, and barriers” cards; there are extra
cards for goal setting, action planning, and dealing with barriers such as
values conflicts, fusion, and so on. In Australia, you can purchase these
at https://www.actmindfully.com.au. For orders outside Australia, go to
https://www.edgarpsych.co.uk/shop.

Facebook Group
The ACT Made Simple Facebook group is a huge online community
where you can share resources, ask questions, discuss struggles and
successes, get the latest updates and free materials from me, and so much
more. Just go to Facebook and search for “ACT Made Simple.”
 APPENDIX B.

Further Training

Live Workshops in Australia

I run live workshops around Australia throughout the year. You can find
details at https://www.actmindfully.com.au. (Unfortunately, I rarely
make it overseas because of the long travel times and horrendous jet lag
—but hey, if you live outside Australia, you can attend my online
trainings, described below.)

Online Courses
I offer a range of online courses in ACT, where you can interact with me
directly via the forum, watch videos of therapy sessions, and access a
stack of specially designed audio, visual, and text-based training
materials. The scope is continually expanding; at the time of writing it
includes the following courses:

Trauma-Focused ACT
ACT for Beginners
ACT for Depression and Anxiety Disorders
ACT for Adolescents
ACT as a Brief Intervention
 ACT for Grief and Loss
ACT for Complex Cases
ACT for Chronic Pain

For more information go to http://www.ImLearningACT.com.

ACBS Website
The mothership organization of ACT and RFT (relational frame theory)
is ACBS: Association for Contextual Behavioral Science. The ACBS
website is truly vast, and in addition to many free resources, you can find
details on ACT trainings, workshops, courses, and conferences
worldwide. You can also join numerous forums and special interest
groups, find an ACT supervisor, find an ACT therapist, and much, much
more. Go to https://www.contextualscience.org.
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Russ Harris is an internationally acclaimed acceptance and commitment
therapy (ACT) trainer, and author of the best-selling ACT-based self-
help book, The Happiness Trap, which has sold more than one million
copies and been published in thirty languages. He is widely renowned
for his ability to teach ACT in a way that is simple, clear, and fun—yet
extremely practical.
 INDEX

A
about this book, 6–7
acceptance, 9; appreciation and, 174–175; cognitive flexibility and, 128–129; duration of
exercises on, 170; exposure and, 156, 158–161, 263–264; four As of, 149–150; grief and, 346;
homework assignment on, 172–173; NAME acronym for, 161–169; resources on, 176; self-as-
context and, 175–176; suicidality and, 308; surfing urges and emotions for, 170–172;
tolerance and pseudo-, 150; words for describing, 149
acceptance and commitment therapy (ACT): brief intervention model for, 360, 361; catch-all
goal for, 63; hexaflex diagram, 9; psychological flexibility in, 11; six core processes of, 8–11;
smartphone app, 370; talking about vs. doing, 57; training courses in, 369–370, 371; triflex
diagram, 11. See also trauma-focused ACT
Acceptance and Commitment Therapy for Borderline Personality Disorder (Ona), 324
ACE formula, 74–78, 94; acknowledge your inner world, 74–75; connect with your body, 76–77;
engage in what you’re doing, 77–78; sequence for using, 86
acknowledging: emotions by name, 162–163; your inner world, 74–75
ACT. See acceptance and commitment therapy
ACT for Anxiety Disorders (Forsyth and Eifert), 156
ACT Made Simple (Harris), 6, 110, 148, 312, 368
Act with Love (Harris), 324, 369
actions: kind deeds and, 185–186; outcomes distinguished from, 50; workable vs. unworkable,
21. See also committed action
agenda for sessions: setting and sequencing, 97–99; working through, 99–101
amygdala, 27
anchor dropping. See dropping anchor
Angelou, Maya, 60
anger stage of grief, 345
antecedents of a behavior, 230–231, 234, 316
anticipatory anxiety, 160–161
anxiety: anticipatory, 160–161; positive functions of, 153; struggling with, 261
anxious-preoccupied attachment, 317
apologizing to clients, 246
Appreciating People exercise, 314
appreciation: acceptance and, 174–175; self-compassion and, 186. See also mindful appreciation
arousal: working with extremes of, 81–85. See also hyperarousal; hypoarousal
assertiveness skills, 227, 278, 323
Association for Contextual Behavioral Science (ACBS) website, 372
attachment styles, 317–318
attachment theory, 179–180, 317–319, 327
attention: shifting, 291, 292; training, 90, 228
auditory defusion techniques, 138–139
autonomic nervous system, 23
avoidance: discomfort, 219; overt, 143; practitioner, 57; self-soothing as, 288–289, 290; task,
160. See also experiential avoidance
awareness, expanding, 135–136, 169, 172
away moves: description of, 21, 42; exploring with clients, 42–43, 113; important points about,
44–45

B
baby steps, 38
backfired experiments, 244–246
bargaining stage of grief, 345
barriers: to self-compassion, 186–192; to therapy goals, 70–71; to values, 203–208
Bear metaphor, 24–27; fight/flight response and, 25–26; freeze/flop response and, 26–27
behavior: functional analysis of, 230–233; rigidity vs. variability of, 218; undermining
problematic, 90–91, 234–238
behavioral goals, 16, 65–69; establishing overt, 65–66; notes on working with, 68–69; seven-day
documentary strategy, 66–68
Berrick, Anthony, 370
blind trust, 325
body, 279–286; connecting with, 76–77, 279–282; homework related to, 285; mindfulness
practices focusing on, 36–37, 282–285; moving and stretching, 282–283; noticing the posture
of, 284; resources on working with, 285; scanning practices, 283–284; self-touch and, 284–
285
body scans, 283–284
bodywork, 36–37
book resources, 368–369
bottom-up approach, 6, 56, 93
Bowlby, John, 179, 180
brain: threat detector of, 27; YouTube animations about, 29
breath: emotions/feelings and, 164, 166, 265; mindful focus on, 36, 76–77; panic attacks and,
261, 264–265
Brief Interventions for Radical Change (Strosahl et al.), 360
brief therapy, 6, 360–363
bull’s eye tool, 97–98

C
Calhoun, Lawrence, 358
caring, value of, 70
Carrot and Stick metaphor, 188
case conceptualization, 16–21
challenge formula, 100–101, 322
change: seven Rs for maintaining, 240–242, 355; transtheoretical stages of, 44
Changing Settings technique, 138
check-ins, 61, 93, 340–341
choice point, 40–53; agenda setting and, 97; away moves and, 42–45; homework task on, 51–52;
interpersonal issues and, 321; introducing to clients, 40–42; reasons for using, 40, 53;
resources related to, 53; summarization of, 50–51, 355–357; towards moves and, 48–49;
unhooking skills and, 45–47
clarifying: defusion through psychoeducation, 125–126; misunderstandings in therapy, 246;
purpose of mindfulness, 37–38
Clinical Manual for Assessment and Treatment of Suicidal Patients (Chiles, Strosahl, and
Roberts), 304
cognitions: defusion strategies for, 110–115, 125; emotions related to, 154, 157; fusion with,
104–105; identifying themes of, 108–110; learning how to notice, 121; questions for
exploring, 107–108; workability of, 112–115. See also thoughts
cognitive behavioral therapy, 21
cognitive defusion. See defusion
cognitive flexibility: committed action and, 225–227; cultivated through ACT, 128–129
cognitive fusion. See fusion
cognitive reappraisal, 176, 226
committed action, 11, 214–229; attention training for, 228; barriers to, 218–221, 240; cognitive
flexibility and, 225–227; goals made into plans for, 215–216, 354; kindness translated into,
184–186; resources about, 228; savoring and appreciating, 224; session example about, 220–
224; setbacks related to, 228, 355; suggesting strategies for, 227–228; suicidality and, 308–
309; values translated into, 214–219; willingness and, 216–217
common humanity, 181, 182–183
communication: “negative” emotions and, 152, 154; pertaining to client safety, 77; relationship
skill of, 323
compassion: for challenging clients, 253–254; inner child exercise of, 331–332; moral injury
and, 302; relationship skill of, 324; self-talk based on, 228. See also self-compassion
Compassion for the Younger You exercise, 331–332
complex trauma, 3
complicated grief, 347–348
comprehensive approach, 6
Computer Screen exercise, 137
conceptualized self, 18, 272, 277
conflict resolution, 324
Connect and Reflect exercise, 197–199
consequences of a behavior, 230–231, 232, 316
contact with the present moment: ACT core process of, 9; mindful appreciation and, 310; trauma
and loss of, 20
control: agenda of emotional, 63, 142, 148; issues of interpersonal, 322–323
Control of Physical Actions (CPA) Scale, 256
core beliefs, fusion with, 19
creative hopelessness (CH), 86, 142–146; client efforts related to, 145–146; dropping the
struggle metaphors, 147–148; Join the DOTS method, 143–144; questions for considering,
142–145, 146

D
debriefing process: dropping anchor, 88–89, 92; Kind Hands exercise, 169; mindful appreciation
exercises, 313; mindfulness practice, 95; urge surfing, 172
defusion, 10; aim of, 105; combining with other ACT processes, 139–141; exercises for, 121–
124, 129; expanding awareness for, 135–136; experiential work and, 161; explanation of, 47,
105; homework assignments on, 126, 139; identifying themes for, 108–110; metaphors related
to, 120; panic attacks and, 262–263; physical movement for, 135; playful techniques of, 136–
139; psychoeducation about, 125–126; resources about, 127, 141; session examples using,
115–120; strategies for, 110–115, 125, 129–136; teaching skills in, 120–126; trust issues and,
324–325; writing and imagining for, 132–135. See also fusion
demands vs. invitations, 38
denial stage of grief, 345
depression stage of grief, 345
detective mode: determining the mind’s purpose in, 111–112; identifying themes in, 109–110;
questioning workability in, 112
diagnosis, fusion with, 56
Diagnostic and Statistical Manual of Mental Disorders (DSM), 5
discomfort avoidance, 219
disconnection from the inner world, 20
disengagement, 20, 90, 228
dismissive-avoidant attachment, 317–318
disorganized attachment, 318
distractibility, 20, 90, 228
distraction: avoidance-based, 291–292; considering methods of, 143, 292; costs related to, 145;
dropping anchor vs., 80, 292; mindfulness vs. techniques of, 35; shifting attention vs., 291,
292
Documentary of You metaphor, 273–275
domino effects, 38
DOTS acronym, 143–144
doubt, defusion from, 115–118
dropping anchor, 72–94; ACE formula for, 74–78, 86, 94; aims of, 78–79; basics of, 72–78;
debriefing process, 88–89, 92; distraction vs., 80, 292; emotional pain and, 80; example of
introducing, 72–73; extremes of arousal and, 81–86; failed experiments and, 245; homework
assignments on, 91–93; length of time for, 86–87; modifications to, 89–91; resources related
to, 94; scaling responses to, 87–88; situations for introducing, 88; troubleshooting, 92–93
dropping the struggle, 147–148

E
eating mindfully, 312–313
Eifert, Georg, 156, 178
EMDR therapy, 6, 342
emergency shutdown mode, 17, 24, 26. See also freeze or flop mode
emotion dysregulation, 151
emotional control: creative hopelessness about, 142, 148; reframing goals about, 63
emotional goals, 16, 62–65; normality of, 63; numbness and, 65; reframing, 62–64; values
confused with, 205–207
emotional intelligence, 281
emotional pain: acknowledging, 181–182; dropping anchor for, 80, 86; self-soothing and, 288–
289, 290
emotional storms, 72–73
emotions/feelings: acknowledging thoughts and, 74–75; appreciation of, 174–175; cognitions
related to, 154; creative hopelessness about controlling, 142; dropping anchor for, 72–73, 79,
80, 85–86; exercise on scrunching, 296–297; flexibly responding to, 151, 156; harnessing the
energy of, 150, 283; identifying themes of, 108–110; making room for, 164–169, 171;
metaphor on layers of, 164; naming, 162–163, 169; positive functions of “negative,” 152;
surfing urges and, 170–172; thinking flexibly about, 176; three components of, 157
ending therapy, 357–358
engaging in what you’re doing, 77–78
evolution: alternative language for, 26; origins of mind related to, 28–29
exercises: Appreciating People, 314; Changing Settings, 138; Compassion for the Younger You,
331–332; Computer Screen, 137; Connect and Reflect, 197–199; Flavoring and Savoring,
213; Getting Out of the River, 130–131; Good Self/Bad Self, 277; Hands as Thoughts, 12–13,
120; Hearing Your Thoughts, 129; “I’m Having the Thought That...,” 122–123; Karaoke Ball,
137–138; Kind Hands, 167–169; Leaves on a Stream, 129; Mindful Eating, 312–313; Naming
the Theme, 123–124; Notice Your Hand, 312; Pushing Away Paper, 14–15, 147; Savoring
Pleasurable Activities, 314; Scrunching Emotions, 296–297; Silly Voices, 138; Singing Your
Thoughts, 138; Slow and Fast, 138; Smartphone Apps, 138; Thoughts on Paper, 136–137;
Transcendent Self, 276–277; Whom Do You Look Up To?, 199. See also metaphors
expanding around feelings, 164, 166
expanding awareness, 135–136, 169, 172
expectancy violation, 265–266
experiential avoidance (EA): catching the act of, 173–174; complicated grief and, 347;
distraction as, 291–292; explanation of, 19–20; suicidality as form of, 306; valued living and,
208
experiments: backfired, 244–246; interventions as, 37
exposure: acceptance and, 156, 158–161, 263–264; case example of, 336–342; checking in
during, 340–341; considerations for formal, 334–335; definition of, 154, 177, 255;
explanation of, 154–156; graded, 156–157, 282; hierarchy of, 266–269, 271; home practice of,
266; imaginal and in vivo, 259; length of time for, 257; memories as target of, 334–344; panic
attacks and, 260–261, 263–266; prolonged, 342; resources related to, 271; response flexibility
and, 155, 156, 257–259; safety factors for, 161; sexual problems and, 270–271; stage for
beginning, 56; TFACT inclusion of, 5; values and, 158, 255–257, 339–340; variable, 271;
willingness and, 269–270
Extra Bits. See resources

F
Facebook group, 370
failures: backfired experiments, 244–246; inevitability of, 364–365
fawn response, 24
fears: exercises evoking, 160; imagining in exposure work, 259; positive functions of, 153
feelings. See emotions/feelings
fight or flight mode, 3; Bear metaphor for, 25–26; perceived threats and, 17, 29; sympathetic
nervous system and, 23, 24, 29
flashbacks, dropping anchor for, 89–90
Flavoring and Savoring exercise, 213, 224
flexibility: cognitive, 128–129; psychological, 3, 11, 21, 327; responding with, 87, 155, 156;
window of, 81
flexible perspective taking, 10, 181, 183, 226
focused acceptance and commitment therapy (FACT), 360, 361
forgiving, 348–352; moral injury and, 302; resentment and, 348; self and others, 349–352; stages
of, 350–352; worksheet about, 351
Forsyth, John, 156, 178
free resources, 7, 368, 370
freeze or flop mode, 3; Bear metaphor for, 26–27; parasympathetic nervous system and, 24, 29;
perceived threats and, 17, 29
Freud, Sigmund, 250
functional analysis, 230–233, 235, 316
functional contextualism, 8
fusion: complicated grief and, 347; with diagnostic labels, 56; explanation of, 17, 104–105;
identifying themes of, 108–110; questions for exploring, 107–108; with reasons, 207–208;
responding to client, 105–106; with rules, 18–19, 139–141, 207; self-compassion and, 186; six
categories of, 18–19. See also defusion
future: fusion with cognitions about, 18; imagining scenarios about, 159; preparing for, 354–359

G
gating and skating, 173
Getting Out of the River exercise, 130–131
Gibran, Kahlil, 365
goals, 16, 62–71; action plans from, 215–216; barriers to establishing, 70–71; behavioral, 65–69;
doubtful, 219; emotional, 62–65, 205–207; extracting values from, 69–70; outcome, 16, 203–
205; questions for setting, 214–215; setting challenging, 160, 354; short- and long-term, 215–
216; SMART acronym for, 215, 354; values distinguished from, 193–194, 203–207
Good Self/Bad Self exercise, 277
Gordon, Judith, 170
graded exposure, 156–157, 282
grief, 345–348; complicated, 347–348; description of, 345; moral injury and, 302; stages of,
345–346; unique process of, 346; working with, 346–347
guarded clients, 160
“Guest House, The” (Rumi), 277
guilt, response to, 293
gut feelings, 280–281

H
habituation, 154–155
Hands as Thoughts exercise, 12–13, 120
Happiness Trap, The (Harris), 368, 369–370
HARD barriers, 218–219, 240, 354
Hayes, Steven C., 5
Hearing Your Thoughts exercise, 129
Hemingway, Ernest, 227
hexaflex diagram, 9
hierarchy of exposure, 266–269, 271
history taking, 60–62
Holt, Albert, 244
homework assignments: on acceptance, 172–173; on body connection, 285; on choice point, 51–
52; on defusion, 126, 139; on dropping anchor, 91–93; on exposure, 266; on mindful
appreciation, 313–314; on self-compassion, 192; on values, 212–213
homework review, 92–93, 97
hopelessness: defusion from, 115–118, 305–307; fusion with, 71
Horror Movie metaphor, 64
How to Forgive Others worksheet, 351
hyperarousal, 3; Bear metaphor for, 25–26; dropping anchor for, 83–85; perceived threats and,
17, 29; sympathetic nervous system and, 23, 24, 29
hyperventilation, 262, 263, 265
hypoarousal, 3; Bear metaphor for, 26–27; dropping anchor for, 81–83; parasympathetic nervous
system and, 24, 29; perceived threats and, 17, 29
 I
illumination function of emotions, 152, 153
“I’m Having the Thought That...” exercise, 122–123
imagery: defusion strategies using, 135, 138; inner child rescripting and, 330; kindness practices
using, 185
imagery rehearsal therapy (IRT), 288
imaginal exposure, 259
impoverished self, 277–278
in vivo exposure, 259
influencing skills, 323
informed consent, 32–33
inhibitory learning theory (IHL), 155, 265, 271
inner child imagery and rescripting, 330
insecure attachment, 180
insomnia problems, 287
integrative approach, 5
interpersonal approach, 5
intimacy: body connection and, 281–282; exposure hierarchy for, 267–269
invitations vs. demands, 38

J
Join the DOTS method, 143–144, 148
“Joy and Sorrow” (Gibran), 365–366
judgments: defusion from, 118–120, 228; fusion with, 18

K
Kabat-Zinn, Jon, 312
Karaoke Ball exercise, 137–138
Kids in the Classroom metaphor, 280
Kind Hands exercise, 167–169
kindness: ACT core processes and, 181; committed actions related to, 184–186; idea of not
deserving, 189–191; self-compassion and, 183–186, 189–191
Kübler-Ross, Elizabeth, 345

L
learning opportunities: backfired experiments as, 246; teamwork troubles as, 251; therapy
failures as, 364–365
Leaves on a Stream exercise, 129
long-term goals, 215–216
Loving-Kindness Meditation, 185, 189, 352

M
magic wand question, 66
Marlatt, Alan, 170
meaningful activities, 200–201
measures used in TFACT, 57
meditation: kind imagery and, 185; Loving-Kindness, 185, 189, 352; mindfulness, 35, 36
memories: dropping anchor for, 89–90; formal exposure to, 56, 334–344; methods of working
with, 342–343; nonjudgmentally naming, 90; reliving, 159
metaphors: Bear, 24–27; Carrot and Stick, 188; Documentary of You, 273–275; Hands as
Thoughts, 120; Horror Movie, 64; Kids in the Classroom, 280; Orphanage, 191–192; Overly
Helpful Friend, 112; Sky and the Weather, 175–176; Struggle Switch, 147–148, 261;
Struggling in Quicksand, 148; Swiss Army Knife, 291; Tug of War with a Monster, 148; Two
Coaches, 188; Two Friends, 179; Wave, 170–172. See also exercises
mind: evolutionary origins of, 28–29; preempting, 141, 335; thanking your own, 125
mindful appreciation, 310–314; brief exercises on, 312–313; debriefing and homework on, 313–
314; introducing to clients, 310–311; resources supporting, 314
mindful check-ins, 93
Mindful Eating exercise, 312–313
mindful trust, 325
mindfulness: ACT core processes of, 10, 181; alternative terms for, 35–36; body practices based
on, 282–285; clarity about purpose of, 37–38; definition of, 35; emotional pain and, 80;
interventions based on, 36–38; moving and stretching with, 282–283; safe practice
recommendations, 39; self-as-context and, 275–277; starting sessions with, 95–97; trauma-
sensitive, 35–39
monitoring activity, 201, 217
moral injury, 299–303; definition of, 299; presentations of, 300; religion/spirituality and, 302;
TFACT work with, 301–302; values work for, 302
moral pain, 299, 300, 303
moral values, 299, 302
morals, definition of, 299
motivation: “negative” emotions and, 152, 153; self-compassion and, 187–188; self-talk and,
226–227; values and, 209–212, 217, 261; willingness and, 217
movement: mindful, 282–283; physical, 135, 264
MP3 audio recordings, 254, 370
Murphy’s law, 244

N
NAME acronym, 161–169
naming: as defusion strategy, 111, 305; emotions/feelings, 162–163, 169; inner experiences, 74–
75
Naming the Theme exercise, 123–124
narratives, fusion with, 19
Neff, Kristin, 180
“negative” emotions, 152
neuroplasticity, 28, 126
Nietzsche, Friedrich, 305
nightmares, 288
nihilism, 71
nonverbal responses, 86
normalizing: client reactions, 61; as defusion strategy, 111, 305
Notice Your Hand exercise, 312
noticing: as defusion strategy, 110, 121, 305; inner experiences, 74–75, 77; physical sensations,
162, 171
noticing self, 183, 272, 275
numbness, emotional, 65
 O
observing: flow of thoughts, 129. See also noticing
online courses, 369–370, 371
optimism, 193
opting out, 143, 145
Orphanage metaphor, 191–192
outcomes: actions vs., 50; goals for, 16, 203–205
Overly Helpful Friend metaphor, 112
overt avoidance, 143

P
pain. See emotional pain
panic attacks, 260–266; defusion practice for, 262–263; exposure for, 260–261, 263–266;
psychoeducation for, 261–262
parasympathetic nervous system (PNS), 23–24, 29
past history: fusion with, 18; working with, 16
physical barriers, 16–17
physical movement, 135, 264, 282–283
physicalizing feelings, 164, 165–166
playful defusion techniques, 136–139; auditory, 138–139; creating your own, 139; visual, 136–
138
polyvagal theory (PVT), 23–24
posttraumatic growth, 358–359
posture, mindfulness of, 284
Potter, Jesse, 218
practice, importance of, 21
practitioners. See therapists
Practitioner’s Barriers Worksheet, 252, 253
preempting the mind, 141, 335
preparing for challenges, 93
Presence Scale, 256
present-moment contact. See contact with the present moment
pressing pause, 33–34, 247
problem hopping, 247–248
problem solving: suicide ideation and, 305–306, 308–309; values-based, 216
problematic behavior, 230–239; alternatives to, 237–238; costs and benefits of, 235–237;
dropping anchor for, 90–91; four steps for undermining, 234–238; functional analysis of, 230–
233, 316; resources about, 238; as session stoppers, 246–249; skills for working with, 238;
triggers of, 234–235
progressive muscle mindfulness (PMM), 283, 284
progressive muscle relaxation (PMR), 283, 284
prolonged exposure (PE), 342
properties of feelings, 164, 165
Prophet, The (Gibran), 365
pseudo-acceptance, 150
psychoeducation: defusion clarified through, 125–126; metaphors used for, 15, 24–27; panic
attacks and, 261–262; shame and, 294–295
psychological flexibility, 3, 21; ACT core processes and, 11; interpersonal relationships and, 327
psychological inflexibility, 3–4, 17
punishing consequences, 230
purpose: of cognitions, 111–112; of mindfulness, 37–38; of shame, 293; of suicidal ideation,
305–306
Pushing Away Paper exercise, 14–15, 147

Q
questions: creative hopelessness, 142–145, 146; goal setting, 214–215; magic wand, 66; thought
exploration, 107–108

R
Reality Slap, The (Harris), 348, 368
reasons, fusion with, 19, 207–208, 219
record keeping, 241
reexperiencing trauma, 3, 17
reflection, practice of, 228, 242
reframing: client problems, 50–51; committed action and, 225; emotional goals, 62–64; suicidal
ideation, 306
refugee camps, 5, 56, 72, 100
reinforcing consequences, 230, 231, 232
reinterpreting situations, 225–226
relapse-prevention plans, 4, 309, 357
relational frame theory (RFT), 8, 372
relationships, 315–327; challenge formula for, 322; emotional intelligence and, 281; skills
development for, 323–324; supportive of new behaviors, 242; TFACT applied to, 319–323,
327; trust issues in, 324–326; understanding problems in, 315–319
relaxation techniques, 36, 283, 284, 291
religion/spirituality: moral injury and, 302; self-compassion and, 189
reminder strategies, 241
repertoire-narrowing stimuli, 155–156
resentment, burden of, 348, 352
resilience vs. posttraumatic growth, 358
resources, 7, 368–372; on acceptance, 176; on body connection, 285; on the brain, 29; on brief
therapy, 363; on choice point, 53; on committed action, 228; on defusion, 127, 141; on
dropping anchor, 94; on exposure, 271; on mindful appreciation, 314; on problematic
behavior, 238; on self-as-context, 278; on self-compassion, 192
response flexibility, 155, 156, 257–259
restructuring the environment, 242
rewards for new behaviors, 241
Rilke, Rainer Maria, 315
Robinson, Patricia, 360
role playing, 223, 224, 324
routines of new behaviors, 241
rules, fusion with, 18–19, 139–141, 207

S
safety: body connection and, 281; communicating about, 77; enhancing in therapy sessions, 30–
34; experiential work and, 161, 257; formal exposure and, 334–335; trauma-sensitive
mindfulness and, 35–39
safety behaviors, 257
Savoring Pleasurable Activities exercise, 314
scheduling activities, 218
schemas, fusion with, 19
Scrunching Emotions exercise, 296–297
seating arrangements, 30
secure attachment, 179–180, 317
self-as-context, 272–278; acceptance and, 175–176; ACT core process of, 10; metaphors for,
273–275; mindfulness practices for, 275–277; practices to develop, 129; resources about, 278
self-care, 227–228, 365
self-compassion, 6, 178–192; ACT core processes and, 11, 181; appreciation and, 186; barriers
to, 186–192; building blocks of, 180–186; definition of, 178; homework assignment on, 192;
introducing to clients, 178–179; kindness and, 167–169, 183–186, 189–191; noticing self and,
183; old wounds opened by, 191–192; resources about, 192; secure attachment and, 179–180;
self-forgiving and, 349; suicidality and, 308; therapist rituals for, 365; Two Friends metaphor
for, 179
self-concept, 18, 272
self-development exercise, 252–253
self-disclosure, 31–32, 186, 250
self-forgiving, 349
self-harm: prioritizing risk of, 99. See also suicidality
self-judgment, 118–120, 182
self-protection, 326
self-soothing, 288–290; activities for, 289–290; avoidance-based, 288–289, 290
self-talk: compassionate, 228; kind, 184; motivational, 226–227
self-touch, 185, 284–285
self-understanding, 71
sensate focus programs, 271
sensations: creating unpleasant, 259; emotions related to, 157; making room for, 164–169;
noticing physical, 162, 171
session stoppers, 246–249
sessions of TFACT. See therapy sessions
seven Rs for maintaining change, 240–242, 355
seven-day documentary strategy, 66–68
sexual abuse: exposure and, 270; shame related to, 295
sexual problems: exposure and, 270–271; self-touch and, 284–285
shaking/trembling response, 283
shame, 293–298; psychoeducation about, 294–295; purpose and benefits of, 293; values work
for, 295–297; workability of responses to, 294
share/care mode, 24
shifting attention, 291, 292
Silly Voices technique, 138
simple trauma, 3
Singing Your Thoughts technique, 138
skating and gating, 173
Sky and the Weather metaphor, 175–176
sky perspective, 183
sleep hygiene, 287–288
Slow and Fast technique, 138
SMART goals, 215, 354
smartphone apps, 139, 370
somatic awareness, 36–37, 282
soul wounds, 2
spirituality. See religion/spirituality
stages of change model, 44
strengths, discovering, 62
stretching, mindful, 282–283
Strosahl, Kirk, 5, 360
Struggle Switch metaphor, 147–148, 261
Struggling in Quicksand metaphor, 148
substance use: considering the strategy of, 144; costs related to, 145
SUDS measure, 256, 271, 342
suicidality, 71, 304–309; committed action for, 308–309; ongoing work for chronic, 309; risk
assessment for, 304; strategies for addressing, 305–309; three “I”s of, 304; values work for,
307–308
Swiss Army Knife metaphor, 291
sympathetic nervous system (SNS), 23, 24, 29
symptoms of trauma, 3–4

T
task avoidance, 160
teacher mode: explaining the mind’s purpose in, 111; identifying themes in, 109; questioning
workability in, 112; values work in, 201–203
teamwork troubles, 99, 250–251
Tedeschi, Richard, 358
telehealth, 7, 12, 41
TFACT. See trauma-focused ACT
thanking the client, 245
Thanking Your Mind strategy, 125
themes: identifying, 108–110; naming, 123–124
therapeutic relationship, 30–31; anchoring clients using, 77; teamwork troubles in, 99, 250–251;
working on ourselves in, 251–253
therapists: common pitfalls for, 56–57; formal measures used by, 57; importance of self-care for,
365; learning opportunities for, 364–365; self-development exercise for, 252–253; self-
disclosure by, 31–32, 186, 250
therapy sessions, 30–34, 95–102; agenda setting for, 97–99; backfired experiments in, 244–246;
brief mindfulness practice in, 95–97; client control in, 34; homework tasks assigned in, 101;
informed consent in, 32–33; preparing for challenging, 253–254; pressing pause in, 33–34;
review of homework in, 97; safely ending, 101; seating arrangements for, 30; self-disclosure
by therapists in, 31–32, 186, 250; sequence suggested for, 95; session stoppers in, 246–249;
teamwork troubles in, 99, 250–251; therapeutic relationship and, 30–31; working through
agendas in, 99–101
thoughts: acknowledging feelings and, 74–75; cognitive flexibility and, 128–129; defusion
strategies for, 110–115, 125; dropping anchor for intrusive, 90; failure to eliminate, 126; form
vs. function of, 105; fusion with, 104–105; identifying themes of, 108–110; observing the
flow of, 129; placing on objects, 135; playing with, 136–139; questions for exploring, 107–
108; relief strategies using, 143–144, 145; responding to client, 106–107; workability of, 112–
115; writing down, 132–135, 335. See also cognitions
Thoughts on Paper exercise, 136–137
threats: amygdala as detector of, 27; responses to perceived, 17
TIMES acronym, 258–259, 266, 335
tolerance: acceptance vs., 150; window of, 81
top-down approach, 6, 56, 93
towards moves: description of, 42; exploring with clients, 48–49
tracking responses, 335
training courses, 369–370, 371
Transcendent Self exercise, 276–277
transdiagnostic approach, 5, 22
transition ritual, 365
trauma: anticipating further, 357; definition of, 2; reexperiencing, 3, 17; symptoms of, 3–4
trauma-focused ACT (TFACT): brief therapy with, 6, 360–363; case conceptualization in, 16–
21; ending therapy in, 357–358; establishing goals for, 16, 62–71; explanation of, 4; exposure
used in, 56; failures experienced in, 364–365; four flexible stages of, 54–56; history taking in,
60–62; measures used in, 57; reason for using, 5–6; sequence recommended for, 86; session
considerations, 30–34, 95–102; training courses in, 369, 371
Trauma-Focused ACT–The Extra Bits (Harris), 7
trauma-related disorder, 3
trauma-sensitive mindfulness, 35–39
traumatic events: definition of, 2; reexperiencing of, 3, 17
triflex diagram, 11
triggers, behavioral, 234–235
trust, 324–326; blind vs. mindful, 325; defusing from issues with, 324–325; underlying values
about, 326
Tug of War with a Monster metaphor, 148
Twain, Mark, 355
Two Coaches metaphor, 188
Two Friends metaphor, 179

U
unhooking skills, 45–47, 219
unworkable actions, 21
urges: emotions related to, 157; exercises evoking, 160; surfing emotions and, 170–172

V
vagus nerve, 23–24
validating reactions, 61, 245
values, 193–213; ACT core process of, 10; barriers to, 203–208; beginning sessions with, 194–
195; bringing into the spotlight, 195–197; cards and checklists of, 201–203, 370; choosing
one’s own, 200; committed action from, 214–219; definition of, 193, 299; exercises for
connecting with, 197–199; exposure process and, 158, 255–257, 339–340; extracting from
goals, 69–70; finding beneath rules, 140; goals distinguished from, 193–194, 203–207;
homework assignments on, 212–213; introducing to clients, 194, 256; moral injury and, 299,
302; motivation and, 209–212, 217, 261; paths to identifying, 200–203; problem solving
based on, 216; remoteness from, 20, 219; shame and work with, 295–297; suicidality and,
307–308; trust issues related to, 326
variable exposure, 271
verbal responses, 86
visual defusion techniques, 136–138
vitality, 279–280
 W
Wave metaphor, 170–172
When Life Hits Hard (Harris), 348, 368
Whom Do You Look Up To? exercise, 199
willingness: acceptance and, 149; committed action and, 216–217; exposure and, 269–270; scale
of, 167, 256
Wilson, Kelly, 5, 197
window of flexibility, 81
window of tolerance, 81
workability: of actions and behaviors, 21; as defusion strategy, 112–115, 140; of relationship
strategies, 323; of responses to shame, 294; of suicidal ideation, 306
World Health Organization (WHO), 5, 72
worry time, 131
writing thoughts down, 132–135, 335

Y
“younger you” exercises, 330–333
YouTube videos: on brain functions, 29; on meanings of “freeze,” 29; on Struggle Switch
metaphor, 148; on Thanking Your Mind strategy, 127