Acceptance and Commitment Therapy Protocol for Developmentally Disabled Psychotic Individuals

Julieann Pankey, M.A., Ph.D. Candidate University of Nevada-Reno

ACT Therapy for Psychosis/Mental Retardation This Protocol: This protocol does not contain an extensive theoretical rationale for the procedures used in this manual. Detailed description of the procedures and theoretical underpinnings can be found in Acceptance and Commitment Therapy (ACT) (Hayes, Strosahl, & Wilson, 1999) and Relational Frame Theory: A Post-Skinnerian Account of Human Language and Cognition (Hayes, Barnes-Holmes, & Roche, 2001). Psychosis and developmental disability: the connection Despite the increasing variety of available anti-psychotic medications, many psychotic individuals are either treatment resistant or experience symptom relapses. Even with medication, a portion of patients with auditory hallucinations and delusions continue to experience these symptoms at least occasionally. Individuals may experience distress related to both positive symptoms such as hallucinations, delusions, and disorganized thought processes; and to negative symptoms, which are more chronic and include emotional withdrawal, loss of speech, social withdrawal, lack of spontaneity and flow of conversation, and blunt affect. The co-morbidity of psychosis in individuals with developmental disabilities may exacerbate the financial strain, emotional turmoil, and difficulties in adaptive functioning that these individuals experience. Given the salience of distress across domains of functioning, there exists a pressing need for more effective interventions to address these populations. ACT and the dually diagnosed population: This ACT protocol draws from basic research in the area of language and cognition. This research, based on Relational Frame Theory, (RFT), suggests that ordinary human processes, particularly those involving language, may be involved in the development of psychopathology. An ACT/RFT model suggests that individuals may fuse odd cognitions with language around the behavior. This process may serve to draw the individual more deeply into a tangled cognition. In effect, active attempts to modify, eliminate, control, or change cognitions may in fact be increasing the frequency and strength of the cognition. An ACT stance requires a radical re-thinking of traditional psychotherapy. Traditional treatments for psychosis focus on reduction in frequency of symptoms, directly challenging the veracity of the positive symptoms, and altering the irrationality related to symptoms. Individuals with mental retardation do not receive ongoing psychotherapy as a general rule. They are more likely served through pharmacological means or through behavior modification plans. An ACT intervention differs in that the treatment technology is not targeted to assist the client in making attempts to modify, eliminate, control, or alter private events (emotions) but rather to begin to notice and accept emotion which triggers using and/or increased frequency of psychotic symptoms. ACT uses metaphorical language framed in terms of historical control agendas, willingness, and values in order to increase acceptance of unavoidable private events such as urges to use

substances and the presence of odd cognitions. The ACT stance rests on noticing aversive emotions and/or bodily states rather than attempting to control them. This ACT protocol situates willingness as the vehicle by which individuals learn that acceptance of aversive private emotion or bodily states is a process, not an outcome. The individual learns that through awareness, vulnerability, flexibility, and willingness one can begin to let go of old control agendas (e.g., increased "buying into" the veracity of delusional ideation) and learn that what needs to change in order to "feel better" is the stance one has in regard to negative private emotions or bodily states, not the emotion or bodily state itself. ACT shifts the focus from modifying the private experience to modifying one's perception of the private experience. To goal is to assist the client in embracing more difficult psychological context while simultaneously focusing on valued overt behavior change. The ACT model suggests that the effectiveness, or workability, of the individual's change effort is the ultimate criterion in that previous, historical attempts by clients to make change in their lives has been often met with failure. Individuals whom have made attempts to directly change hallucinations or delusions may have experienced a paradoxical increase in positive psychosis. This increase is in a sense, unworkable in that not only is it not alleviating symptoms but it is in effect, exacerbating the situation. ACT proposes that these past attempts are unworkable in that a willingness to notice odd cognitions without active attempts to control or modify them may increase client outcomes. Some basic hypotheses: 1) Delusions are often avoidance maintained and a process or form of emotional avoidance. The highly verbal nature related to experiencing and reporting of delusional states and the difficulty parsing cognitive limitations from psychopathology contributes to the difficult challenge of treatment intervention in this population. A thought disordered individual may desire to maintain the delusional state, given the distress caused by having the thoughts in the first place. The presence of an intellectual disability may provide the individual more difficulties and distress. Given the salience of cognitive entanglement around delusional thought processes, they may be less ameliorable to treatment intervention than hallucinations. 2) Hallucinations are more often an outcome target for psychotic individuals in that they are often a target for suppression, as individuals report more subjective distress related to auditory and other sensory intrusions and wish hallucinations would go away. Given this, clients may embrace more active attempts to control or eliminate them. Because hallucinations may be more easily targeted, ACT strategies based on acceptance can be delivered around the hallucination with the ultimate target being generalization to delusions and other avoidance strategies which are less tolerant to direct intervention. 3) If delusions themselves are verbal avoidance strategies, it is not so much the delusional process that needs to be accepted but rather the feelings of failure,

depression, anxiety, and so on that the delusions help regulate (Bach and Hayes, 2002). Synthesis: This ACT protocol is has been designed to target a dually diagnosed population. ACT technology based on acceptance and change strategies will be employed to decrease believability of symptoms, decrease distress related to positive and negative symptoms, increase adaptive functioning, and increase medication compliance.

Session Outline Targets Intervention

Pre Assessment Rapport building/TX plan Confidentiality/informed consent Assess adaptive functioning Assess interpersonal repertoire including primary hallucination/delusion classes Assess medication compliance (issue of context/workability) Take history of substance use Two Mountains and Dirty Glass metaphors Session One Check in Noticing and naming thoughts (distancing exercise) Discuss continuum between psychotic symptoms and other thoughts. The problem is not the symptoms per se; but rather how one responds, e.g., notice not act/believe Reasons are a DEAD END Explore past coping efforts/workability

Thoughts River exercise Tug of War metaphor

Discuss successful working Session Two Check in. Noticing thoughts/defusion Discuss notion of link between thoughts and them "causing" distress. Reasons are NOT CAUSES Discuss notion of needing to be "right"

Sell Me A Reason exercise List and discuss costs of using and/or "buying into" odd cognitions Tour Guide metaphor

Thoughts River exercise Museum of Reasons metaphor. Discuss dusty, well hovered over artifacts. Down in the Cellar metaphor Invitation to the Room metaphor

Control as a problem/Letting go of the struggle Normalize experiences urges/positive and negative symptoms Have the client list symptoms in detail, how distressing they are, and how they attempt to control them Willingness/Acceptance

Wearing Symptoms List symptoms on differing cards. Ask client to pin them on, or in effect, to wear them on themselves

Session Three

Check in. Noticing thoughts/defusion/ Introduce believability Distancing with defusion as a target Discuss issues of function of odd cognitions/urges to use rather than focusing on form or frequency Language around thoughtsbarriers to acceptance

Goals and Action

Thoughts Pie/ % True" Sticky clumps of yarn metaphor Thoughts Parade metaphor Hierarchical noticing "I'm having the thought that" Getting off of our buts/and Commitment and goals Shield of Armor metaphor

Session Four

Check in. Noticing thoughts/defusion Values as a context to place action/goals Discuss goals, action, and barriers Past control attempts have hindered successful working Commitment to self

Thoughts River exercise Values Highway exercise

Stones to Make a Bridge Self in Chair exercise Eyes Forward not Back Focus on valued activities, not reduction of symptoms per se Stand Up and Tell Me Session Five Check in. Noticing thoughts/defusion/believability exercise Willingness/exposure

Thoughts Pie/ %"true" Willingness to have odd cognitions and/or urges to use Objects on the Table metaphor--Draw color and shape of urges and odd cognitions exercise Distinguish between descriptions and judgments of self. Court Reporter, Lawyer, and Judge metaphor

Description and evaluation of behavior and self

Session Six

Check in. Noticing thoughts/defusion

Experience and self as context Acceptance

Thoughts River exercise Box of Marbles metaphor Hallway with Rooms Sitting on the Beach Accept all, even if some parts are not as well liked I am. (period) exercise

Session Seven

Check in. Interpersonal relationships/values Flexibility

Control as a problem/letting go/coping with urges Bathed in your own experience Acceptance

Matter O Meter Social Dance metaphor One Note on the Piano Thoughts as bullies Sound out/Sing/Silly voice Rumpled Old Shoe Lighthouse metaphor Your mind is not your friend, your experience is your friend. Whole not broken

Session Eight

Check in. Wrap up of ACT targets--

1) continuity of thoughts 2) distancing from symptoms 3) valued life process 4) action based on values not symptoms

Saying Goodbye

5) successful working in adaptive domains 6) relapse prevention History is additive so now this is part of their history Tying it all together-Spiral Staircase metaphor

Pre-Treatment Assessment Targets of Pre-Treatment Assessment: 1. Rapport building/tx plan building Introduce self and discuss credentials, review number of sessions that will take place. Explain the flexibility of the program and the overarching goals of the treatment. Discuss with the client limits to confidentiality. Discuss the informed consent form and ask them to sign it. Introduce the Two Mountains metaphor and the Dirty Glass metaphor**ACT handbook 2. Assessment of adaptive functioning (self report). Address communication, daily living skills, personal hygiene, socialization, motor skills, and psychotropic medication history including compliance. (Follow up with an additional adaptive assessment with another individual who has access to the client's functioning for at least the prior six months). Primary targets for assessment are: Current diagnoses and current medications. Assess compliance. Ongoing medical needs and history of psych hospitalization Hierarchy of major barriers related to adaptive functioning 3. Assess interpersonal repertoire and create case conceptualization based on classes of functioning e.g., behaviors which are avoidance moves for the client such as primary hallucinations and delusions. Create a hierarchy of interpersonal functioning for the client based on what classes of behavior are most interfering with the individual's adaptive functioning, ability to communicate needs, ability to discriminate problems and barriers they are facing, and past change efforts. Primary targets for assessment are: Detail behaviors which function as avoidance moves (e.g., psychotic symptoms, drug use and/or other behaviors such as over eating or sleeping, self injurious behavior, etc.) Detail behaviors which function to limit interpersonal closeness (e.g., any interpersonal communication strategies which seem to be limiting adaptive functioning or serving to function as ways to avoid such as being too direct, overly aggressive, too passive, or too guarded. Discuss their sense of willingness to change

Session One Session Targets: A) Noticing and naming thoughts B) Letting go of the struggle C) Function of reasons D) Workability 1. Check In. Check in with the client. Did they have any thoughts left over from last week? 2. River of Thoughts Metaphor. Introduce the notion of thoughts as a part of us that occur on a continuum. Ask the client to begin by drawing on a sheet of paper a huge river designed with big squiggle lines. Ask the client to fill in the river a sample of the "thoughts that they had during the week. Encourage the client to place all thoughts that occur to them within the lines, including "bad" thoughts and "good thoughts." Go over the River of Thoughts with the client, discussing the function of the differing thoughts on how the individual perceives their world. Discuss the continuum between psychotic thoughts and other thoughts. Target for the client the distinction between "buying a thought as a fact," and "simply noticing it." Tell the client that the primary problem you are going to work on is not the thoughts per se, but rather how one responds to the thoughts through action, judgments, or active attempts to control the thought. 3. Tug of War Metaphor (Hayes et al., 1999 p. 109). Discuss how "dropping the rope" as a metaphorical move exposes a person to the idea of letting go of futile struggles. Link the tug of war metaphor back to the River of Thoughts the individual drew. Discuss how letting go of some of the struggle with these thoughts teaches the person to simply notice the struggle rather than attempt to control it. Ask the client to imagine floating on a boat in the River of Thoughts, and just simply participating in the ride without attempting to modify the trip. Point out that the action is now situated in the noticing, rather than active "doing." Use examples which fit the client's experiences to link the ACT theoretical stance related to letting go of struggles with the client's actual struggles with thoughts /bodily sensations/positive and negative symptoms. 4. Sell Me a Reason Exercise. Discuss with the client how elaborate reason-giving is a trap. (Hayes et al., pp. 163-166). Have the client try and "Sell to You" the "reason" why letting go of the above thoughts and struggles is difficult. Encourage the client to continue with more and more elaborate "stories," by continuing to say to them "more reasons please." Don't try and disagree or directly attempt to test the veracity of the statements. Continue until the client says there are no more reasons. Try and convince them to come up with more reasons. As the client becomes increasingly disregulated, stop and discuss with them that this exercise demonstrates experientially that that reason-giving is like a hall of mirrors that continues to reflect into infinity. Point

out that there is no true peace found through hunting for the "Great and Golden Reason Why." Attempt to undermine the client's confidence in reasons. This is in service of beginning a discussion of workability. Human beings will always have "reasons" for behavior. The ACT stance is not one of attempting to eliminate reasons per se. It is rather to help the client focus on reasons as private experiences that should be attended to or followed only if it works to do so. 5. Workability. Exploration of Past Coping Efforts. Collect a history of past coping efforts. Discuss patterns of drug usage, behavioral problems, etc. Gather history of the impact the client's past coping has had on a number of life domains including interpersonal relationships, physical health, and employment. If the client has insight into the function of positive and/or negative symptoms of psychosis serving as avoidance mechanisms, introduce the idea of how "buying into" these thoughts represented in the beginning of session in the Thoughts River costs them vitality. Discuss substance use and "buying into" odd cognitions as missed opportunities for a more successful way to manage ones life. Discuss past coping efforts (e.g., "what the client has tried in the past") in terms of the workability of a coping effort (Hayes et al., p. 94-95). The ACT model proposes workability as the ultimate truth criterion with regard to attempts to modify undesirable psychology content. Unworkable strategies ultimately are that--unworkable. Successful working occurs when an individual maintains an active engagement in one's life, living a valued, vital existence which retains contact with one's direct experience. Discuss workability in terms of the client letting their own experience be their tour guide. Tour Guide Metaphor. Have the client conclude session by pretending to be on a tour bus and offering a tour to the therapist. The "sights" along the tour are the client's past attempts at change. Encourage the client to describe without judgment (e.g., no words like 'this is the worst thing I tried,' or 'this is bad') the differing ways they have attempted to cope in the past. Conclude session by describing how ACT challenges a person's reliance on verbal rules and asks them to instead look to their own experience ("a tour of their own life") for their own "tour guide." Here, the focus is on consequences of behavior and the process of noticing them. The therapist can continually orient the client by asking "What does your experience tell you?" or "How did that work for you?" to begin to encourage the client to look at past change efforts without judgment as to right/wrong or good/bad, but to test them against the ultimate criterion of how successful they "worked" for them.

Session Two Session Targets: A) Noticing thoughts/defusion B) Reasons are not causes/right & wrong C) Control as a problem D) Thoughts and their link to distress E) Symptom detail/exposure 1. Check In. Check in with the client. Did they have any thoughts left over from last week? 2. River of Thoughts Metaphor. Reintroduce the notion of thoughts as a part of us that occur on a continuum. Ask the client to again draw on a sheet of paper a huge river designed with big squiggle lines. Ask the client to fill in the river a sample of the "thoughts that they had during the week. Encourage the client to place all thoughts that occur to them within the lines, including "bad" thoughts and "good thoughts." Go over the River of Thoughts with the client, discussing the function of the differing thoughts on perception of the world. Discuss the continuum between psychotic thoughts and other thoughts. Target for the client the distinction between "buying a thought as a fact," and "simply noticing it." Tell the client that the primary problem you are going to work on is not the thoughts per se, but rather how one responds to the thoughts through action, judgments, or active attempts to control the thought. Tell the client that the "river of thoughts" is something that you will be revisiting frequently during this treatment, both in referencing the thoughts themselves, but in continuing to reinforce the behavior of "simply noticing thoughts" without attempt to control them or attending to them as "causes of behavior." 3. Reasons Are Not Causes. Discuss the notion of a perceived link between thoughts and their "causation" of distress. Remind the client that we have already discussed the trap that reasons can be, in that reasons offer little psychological peace in the long run and are a never-ending bottomless pit. Reasons are *also* a problem in that individuals can begin to have elaborate "stories" about reasons "why" they continue to use substances, or continue to engage in elaborate or odd cognitions. (Hayes et al., pp. 163-164). It is often very difficult for individuals to step back from well worn and treasured "reasons why." "Reasons why" can also take the form of "reasons that are right," which folds into a form of righteous indignation whereby the individual is more concerned with the "rightness" of the verbal story around an event or behavior rather than the functional utility that telling the story or fusing with "rightness" serves them. Introduce the idea of a Museum of Reasons. Ask the client to imagine a museum that is well tended by them, well hovered over. The pieces on display represent stories related to "reasons why." There is a special shrine of "favored" pieces

represented by Righteous Indignation. Ask the client which pieces are so old they are dusty. Have the client describe how and when some of the pieces arrived, and which ones are the most well tended. Describe how reasons that are well tended in this manner are missed opportunities for a vital life. Introduce the notion that these historical artifacts are governing the way the client is currently living their life. Discuss ways the individual is actively attempting to control or avoid current experience by focusing on past "wrongs" and "reasons." Link current struggles with historical struggles in order to begin to teach the client to discriminate patterns. 4. Control as a Problem (Hayes, et al., pp. 115-147). Discuss the trap related to active attempts to control or modify thoughts or bodily sensations. In effect, attempts to control experience may paradoxically serve to increase The form or frequency of the experience. Control as a problem can be experientially demonstrated through the sequence of exercises below: Down in the Cellar Exercise. Have the client chose a "well worn" thought that is causing them some distress. Have them imagine that they "hide" the thought downstairs in the cellar of their mind. Have the client get creative in their descriptions, e.g., down the rickety steps, under the aging wood, under a trap door well hidden and covered with blankets and locked with a nice, big, shiny lock and key. Now have the client imagine themselves upstairs in the house, wandering around, trying *not* to think about the hidden thought down under the stairs in the cellar. Highlight how trying to "hide" from the thought or to actively "hide" the thought actually makes it more difficult to forget. Invitation to the Room Exercise. Now have the client imagine they are sitting in the most comfortable place in the "room of their mind." Have the client detail this room, what it looks, feels, and smells like. Tell the client that the thought that they tried to hide in the cellar is standing outside the door. Are they willing to let the thought come inside? Discuss the paradoxical effects of attempts to keep the door closed. Validate the client's concerns related to fear of opening the door. Suggest that you are willing to sit in there with them, if they are willing. Highlight that "willing to be willing" is the step we want to have them make. It is one step removed from the action of "willing" itself. If the client is willing to "let the thought in," have them detail the process, relating feelings of distress and noticing thoughts that their mind is giving them. Have the client notice bodily sensations and any active attempts to control the experience of "letting the thought in the door." Have the client talk about what the thought is doing in the room, whether it is silent, aggressive, what color it is, what shape it is, etc. Encourage them to be creative. If the client is willing, ask them to allow a few "thoughts" to come in the room. Have them describe each one, including how they are all interacting with each other. Normalize and validate distress related symptoms. 5. Physicalizing Exercise/ Wearing Thoughts and Symptoms.

Now that the client is "sitting in the room" with some of their thoughts and has described their physical appearance in detail, introduce a small deck of blank flash cards. Ask the client to write down a brief descriptor of the thoughts on the cards (e.g., "black colored pain," "Im going to panic," "heart with a big X over it"). Once the client has done so, ask the client if they are willing to take one more step towards being willing to put down attempts to control these thoughts. Ask the client if they will either pin the cards to their jacket or carry them in their pocket or purse for the next week. Discuss how being willing to accept negative thoughts and symptoms creates a context whereby "active control" is not necessary anymore. Have the client describe their sense of willingness to complete this homework. Discuss the homework in terms of increasing willingness.

Session Three Session Targets: A) Defusion and believability B) Distancing with defusion as a target C) Language around thoughts D) Values, goals, action, and barriers 1. Check In. Check in with the client. Did they have any thoughts left over from last week. 2. Noticing/Defusion/Believability. (Hayes et al., p. 148-163.) Introduce a discussion around defusion. The client has already participated the previous two sessions in the Thoughts River exercise, so continue to highlight that we are targeting the relationship to the thoughts that our minds give us. Discuss defusion in terms of thoughts tangled in our minds like sticky clumps of yarn. Describe to the client how thoughts or elaborate verbal "stories" we create can fuse with other cognitions and/or aversive bodily states to the degree which it interferes with current functioning. For example, a client may have a core story around that is rigidly held. This "story" is composed of thoughts related to "who they are," and "what their problem" is. Have the client notice what their own mind "says" to them when you ask them about who they are and what their problem is. Discuss how one's own mind can become excessively fused with these "stories," and how such fusion can create more suffering and make willingness to change impossible because a person spends energy focused on the story rather than making actual progress on the underlying problem or distress. Introduce the Thoughts Pie, % True exercise. Have the client draw a pie chart and place some of their thoughts for the week in the pie chart. Have the client orient to which "pieces" (thoughts/urges/bodily sensations) took up more of a % of the week than others. This is beginning to teach hierarchical noticing. We want the client to begin to notice which thoughts are "taking up more space" than others. After the pie chart is filled in, the client will have thoughts that took up, say 10% of the week, and others that took up much more. Tell the client that we are not generating percentages in order to parse out a "why" one is more salient than the other. It is important to make the point that "why" is a dead end street. We could generate "why" until the next century. The point of this exercise is to (again) simply notice the thoughts and to begin to even further discriminate them by noticing volume. It is simply a more subtle, nuanced, version of the Thoughts River. If the client can become adapt at "simply noticing" which thoughts are somewhat dominant (without generating a "why"), the relationship between the thought and behavior changes. After the pie chart is filled in, ask the client to tell you which ones are "true." Are all the thoughts "true" with a capital T? Challenge the client by telling them that "truth" (like "why" and "reasons about" are dead end, unworkable strategies. They deflect by changing the focus from the actual issues one is distressed about to becoming mired in dead end tangles and verbal wrestling matches whereby "your mind" gives you arguments as to whether things are "true/not true."

Discuss with client "truth" in terms of what works as a process, rather than a focus on a "truth" outcome. Describe "truth" in terms of pragmatic, working strategies for life rather than a focus on "unearthing" truth. (Hayes et al., p. 19-20). Have the client notice that distancing from a thought automatically shifts the focus from "how believable it is" to "just noticing it." This is one powerful way that clients can learn to disengage from "buying into" believability. More discussion of distancing from thoughts can be described in terms of the Thoughts Parade metaphor (ACT Handbook). Have the client imagine they are sitting in the grandstand next to a parade going by. Have them imagine that people walking in the parade have big, white cardboard signs with sentences on them that reflect what the client's mind "thinks about." Essentially, these sentences are what is expressed in the River of Thoughts, but the target here is noticing an even greater "distancing effect." Have the client notice the distance between the parade of thoughts and sitting in the grandstand. Discuss with the client willingness to simply watch the thoughts, and how the thoughts function for them (e.g., have them begin to notice if particular thoughts cause more negative arousal). Encourage them at all times to simply notice the thoughts, while validating that this process may feel fearful. Introduce the idea that there is "language" between the placards in the form of words in patterns, reasons, and most importantly, the word "but." 3. Language Around Thoughts: Barriers to Acceptance. Briefly discuss how language around thoughts can be barriers to acceptance. A major target is an assault on the client's use of the word "but." But is commonly used to specify exceptions, carrying with it an implicit statement about the organization of psychological events. For example, the client may "see" in their parade of thoughts a placard which reads "I love my wife," and on another a sentence which reads "She hurt me." Human beings tend to insert "but" between the sentences reflected "in the parade." The word "but" automatically draws us into a struggle with our thoughts and feelings in that it pits one set of thoughts/feelings against another. Learning differing ways "to language" is one way ACT serves to help the client create distance between the client and the products of the client's mind. Discuss the And/But distinction (see Hayes et al., pp. 166-167). 5. Values, Goals, Action and Barriers. Discuss change in terms of commitment to action (Hayes et al., pp. 235-280). Offer a conceptual discussion related to the differences between goals, action, and values. The ACT stance is one of values being an overarching context for action whereby goals are more behavioral landmarks along the way. Tell the client that the next session we will be generating values, but for now, we are simply discussing goals and action. Have the client generate goals tied to therapy and functioning outcomes. Describe how the most important part of goals analysis is to maintain a close connection between the action and its associated goal (and in turn, its associated context of values). Have the client generate a candid analysis of barriers the client is experiencing in therapy. Discuss barriers in terms of life

processes, and more global barriers to functioning. If the client cannot identify meaningful barriers, discuss how urges to use might function as barriers. Have the client draw a Shield of Armor on a piece of paper. Have them write their name on the shield and to write on it what type of shield it is, e.g., have them imagine that barriers to action in their lives like urges to use, actual substance use, buying odd cognitions as fact, etc. act like an avoidance shield which deflects "life" away from them. Discuss barriers in terms of what they are costing the client across domains of functioning, e.g., spiritually, emotionally, and physically. Describe how thoughts and feelings are not always the best guides for behavior, compared to goals based on values.

Session Four Session Targets: A) Noticing thoughts/defusion B) Values C) Action and Barriers D) Commitment to self 1. Check In. Check in with the client. Did they have any thoughts left over from last week? 2. Discussion of Values/Values Highway Discuss with the client that ACT is a values-oriented approach. From an ACT perspective, acceptance of negatively evaluated thoughts, memories, emotions, and other private events is always in service of ends which are valued by the client. Describe the difference between values and goals. From an ACT stance, values have action and purpose. So do goals. The content is often the same. The only difference is content, in that values represent overarching contexts related to "ways of being," while goals are specific behavioral landmarks along the way. A goal points to an end state and a value points to an ongoing act or way of being. Have the client draw a highway on a sheet of paper. Have them visualize the highway as their Values Highway. Have them write in the differing values that they ascribe to. Ask them to describe values related to relationships, health, employment, education, recreation, spirituality, etc. Have them draw "signposts" along the way which represent differing goals that they have. Encourage the client to place all values that occur to them within the highway. If the client has difficulty with values generation, validate their distress and attempt to help them uncover their values. If the client generates values which seem purely to be controlled by either cultural approval or therapist approval probe further for how removing perceived consequences by the culture or the therapist would modify or change the value. Go over the Values Highway with the client, discussing the function of the differing values on how the individual perceives their life. Discuss the importance of seeing life as a process, not an outcome. It is about a meta-value of "valuing" the trip rather than a specific destination. 3. Barriers to Goals/Values: Building a Bridge. Revisit some of the barriers the client generated the previous session in the form of "shields." Discuss that one way to lessen the function of a barrier is simply to "put down the shield." Another way is to imagine ways to allow the shield to work in and of itself, to find acceptance. This can be discussed in terms of the Building a Bridge metaphor. Have the client imagine that they have access to huge pieces of stone and granite. They also have access to "chiseling" machines and can chisel on the rocks differing sentences reflecting barriers to values/action and goals that they are experiencing. Discuss how even "getting present" with these painful private events can be hurtful, much less going through the motion of chiseling them into

rock. Have the client imagine that at the end of the day there are a number of rocks sitting the quarry. These rocks represent their differing "barriers and struggles." Tell the client that there is a "road" to acceptance; but that there is a huge river cutting across the road and that they need to make a bridge over it. Tell the client that their "struggle rocks" are magic rocks and only they can be used to build the bridge over the river. Have the client imagine an attempt at a warm, positive feeling toward the pile of rocks. Discuss how the client could take those rocks, and metaphorically, "use" them as pieces to build a bridge. Tell them that the bridge is the way to acceptance, and only these special rocks can help them build it. Only in "getting with" the rocks and assembling them together, as a whole, as pieces of themselves that they are not trying to control or eliminate, can they "build the bridge" to acceptance. 4. Commitment to self. Discuss commitment to self as the vehicle by which change can occur. Commitment can occur through overt behavioral action, or by taking some of the privately mediated steps suggested by ACT. Discuss willingness as the vehicle to commitment. If we are willing to "build a bridge" from our barriers, then we are setting the stage for barriers to be dissolved. Describe to the client that willingness is the primary condition for committed action and that it is not wanting but an act of choice. Tell the client that there is no such thing as being partly willing. Self-acceptance can allow commitment to be kept. Have the client orient to the path in front of them. Commitment involves eliciting and sustaining behavior change. Discuss with the client that they will be tempted to "look behind them," in that they will feel the pull to orient to old, historical ways of engaging action. This may even bring up feelings of failure and/or a feeling of resignation. Encourage them to keep "eyes forward," or "eyes at the here and now," in order to continually orient to the process in the here and now. Change is a process that you commit to every day, on the hour. Discuss with the client barriers to commitment as expressed by the algorithm FEAR (Hayes et al., p. 246). They are Fusion with thoughts, Evaluation of experiences, Avoidance of your experiences, and Reason giving for your behavior. Tie these barriers to actual experiences and struggles the client is experiencing. Have the client undergo a "Commitment to Self" exercise. Have them sit in the chair and close their eyes, imagining that the "core of themselves" is sitting across from them in another chair. Have them talk aloud and make a commitment to that self. Encourage them to discuss "with themselves" how barriers to action can be understood from an ACT perspective. Have them provide "themselves" with a context of willingness that they are willing to "support the self in." Have the client talk with the self about fears of failure and how it is possible to have that fear and to continue forward anyway. Discuss with the client the utility of emphasizing the process of committed behavior and de-emphasizing the outcome of committed behavior. Have the client "make a vow" to themselves to practice willingness as a vehicle for committed action.

Ask the client if they feel they have clarity around values and how they can function as a context for change. Ask the client if they are willing to Stand Up and Tell Me their values. Encourage the client to stand in the room, maintaining eye contact. Have them attempt to "stay present" with the thoughts that they may be having (e.g., thinking you may be 'judging' them) and to simply notice those thoughts and not act upon them. Have them try this even if they are uncomfortable about speaking out about values in order to demonstrate experientially the process of having discomfort and telling it anyway. This is like life in that we can be challenged and move forward in valued life directions.

Session Five Session Targets: A) Defusion/believability B) Willingness C) Evaluation of self 1. Check In. Check in with the client. Did they have any thoughts left over from last week? 2. Defusion/believability. Have the client complete the Thoughts Pie, % True exercise from Session Three. Have the client draw a pie chart and place some of their thoughts for the week in the pie chart. Have the client orient to which "pieces" (thoughts/urges/bodily sensations) took up more of a % of the week than others. This is continuing to teach hierarchical noticing. We want the client continue to notice which thoughts are "taking up more space" than others. After the pie chart is filled in, the client will have thoughts that took up, say 10% of the week, and others that took up much more. Tell the client that we are not generating percentages in order to parse out a "why" one is more salient than the other. It is important to make the point that "why" is a dead end street. We could generate "why" until the next century. The point of this exercise is to (again) simply notice the thoughts and to begin to even further discriminate them by noticing volume. It is simply a more subtle, nuanced, version of the Thoughts River. If the client can become adapt at "simply noticing" which thoughts are somewhat dominant (without generating a "why"), the relationship between the thought and behavior changes. 3. Willingness. Tell the client that we are going to add a slightly different twist to the Thoughts Pie during this session. We are doing to talk about the thoughts in terms of willingness. Have the client close their eyes and talk aloud to you, imagining each of the thoughts from their Thoughts Pie as an object sitting on a long table. The exercise is to have the client Physicalize and describe each thought--through color, shape, odor, etc. Once the metaphor of all the thoughts are "Objects on the Table," have client pretend in their mind's eye that you are asking them to sit down at the table. How willing are they to do so? Discuss willingness in terms of what is lost when we are not willing (Hayes et al., pp.136-138). Have the client imagine sitting down at the table and being willing to pick up the objects, one by one. Have them describe thoughts/feelings/bodily sensations they notice as they "pick each one up." Validate willingness in the face of fear. 4. Description versus Evaluation of Self. While previously we have focused more on thoughts/odd cognitions/aversive bodily sensations and/or urges and distancing from evaluations/judgments about them, we are now turning the focus to description versus evaluation of "self." Tell the client that our next session will focus almost entirely on acceptance and "the self." Discuss with them that for this session, however, we will simply be

discussing the difference between evaluation and description (e.g., that is a 'good' movie versus 'that is a movie'). Have the client generate "evaluations" they may have, or judgments they may have about themselves. Discuss this in terms of a change in stance we are asking them to make. Introduce the Court Recorder, Lawyer, and Judge metaphor. Have the client "pitch" something they are judging themselves about (e.g., urges to use or actual using behavior). Have them give an elaborate "concluding argument" that is meant to persuade the jury that something is "good or bad." Discuss how the lawyer is coming from a point of view, and is actively attempting to sway the audience, by offering a litany of behaviors in a string and attempting to create a "story." Describe how the judge and/or jury are taking in the information and attempting to offer evaluation and/or judgment related to the description of facts. Have the client notice that the court recorder is simply sitting in the corner, recording a) the literal descriptions, b) the story telling and attempts at persuasion and c) the judgment/evaluation. The point for the client to understand here is that we can have differing ways of engaging the sense of self (e.g., I've been jailed because of my behavior when I was using), and we can "pitch" it from a perspective, (that really sucked and I hated it) and finally, we can evaluate and judge (I'm bad because of it). The target for this metaphor is to orient the client's focus to the court recorder, who is actively and faithfully (simply) noticing and recording. We want to steer the client away from active attempts at a) elaborate, persuasive story telling around "reasons," (Session One and Two), b)"right/wrongs" (Session Two), and c) judgments about self which almost always fuse a behavior with whom one is (e.g., I use drugs and that is bad, so I'm badwhich simplifies in a person's mind to be bad equals me). Once the client understands that the target is the relationship between the thought and the experience of it, not the thought per se, or the experience per se, we have laid the groundwork for the next session, which will discuss the difference between conceptualized content ("self as content") versus core, experiential 'beingness' ("self as context") (Hayes et al., pp. 180-189). Tell the client to come prepared next session to discuss self and how we "language" about self.

Session Six Session Targets: A) Noticing thoughts/defusion B) Self as context versus self as content C) Acceptance 1. Check In. Check in with the client. Did they have any thoughts left over from last week? 2. River of Thoughts Metaphor (Self as Content Version). Take a short time to reorient the client with the notion of thoughts as a part of us that occur on a continuum. Ask the client to again draw on a sheet of paper a huge river designed with big squiggle lines. Ask the client to fill in the river a sample of the "thoughts that they had during the week; but have the client focus specifically on "thoughts they had about themselves," this past week. Encourage the client to place all thoughts that occur to them within the lines, including "bad" thoughts and "good thoughts" about self. Go over the River of Thoughts with the client, discussing the function of the differing thoughts on their perception of "self." Have the client notice statements which have the phrase "I am" in them. An ACT model assumes that it is this particular type of statement which creates severe problems because this conceptualized self (e.g., I am good, or I am an ugly person) is resistant to change (protected and defended) and can foster selfdeception. An ACT stance is one of helping clients to distinguish themselves from their conceptualized content, however "good" or "bad" that content may be. 3. Self as Context versus Self as Content. Take examples from the client's River of Thoughts and discuss them in terms of how the individual perceives their world. Discuss the River in terms of self as content and the "conceptualized self." (Hayes et al., pp. 181-182). Most likely *all* of the thoughts the client has written in their River are related to how they construct, view, or understand their own sense of themselves, and are directly tied to an evaluation, perspective held, or judgment they hold. Ironically, individuals may work to defend their conceptualized self even if the content is loathsome to them because the process of "buying into" the thought that they are "good, bad, pretty, smart," etc. is such an old, familiar, and comfortable strategy. 4. Self as Context Metaphors. Discuss self as context in terms of self-identity. Self-identity is best tied to self as context. Introduce to the client the notion that they are not defined by private experiences; but rather, that they are the conscious vessel that contains private experience. Self as context is the immutable location or point of view from which humans report all events and as such, the self as context forms the context for the ongoing process of verbal behavior. Discuss how this idea of "self as context" has a transcendental quality about it. In effect, this transcendental quality involves verbally discriminating the contents of one's awareness but not evaluating, conceptualizing, or comparing those events. Describe for the client

there is a difference in seeing one's self as products of behavior (self as content) and seeing oneself as the point from which all behavior emerges (self as context). There are various ways to discuss self as context. (See Hayes et al., pp. 190-198). This protocol presents a more "physicalized" version of self as context, in an effort to target a more cognitively disordered population which may have difficulty with the concept. The primary ACT metaphor for self as context presented in this protocol is the Self as Context Beam. Clients may have difficulty understanding the concept of a "transcendental" self. In order to represent self as context, ask the client to close their eyes and imagine that ever since they were born, they have literally been "standing" in life. Ask them to imagine that right out of the womb, a piece of them has been able to stand and look in front of them. It is no more complicated than that, just standing and looking forward. Ask the client to imagine that to one side or the other, whichever side feels more comfortable and "correct" to them, there is a wooden handrail. It began as they began, and hovers in space, next to them. The wood is cool, and comforting. It is a smooth, burnished, pretty wood. As they begin to "walk forward" on the path of life, that orienting beam continues with them. It is never wavering and magically, one of their hands can never, ever, be removed from it. It represents their "bottom line" in that it is the most core piece of them. It is unchanging in that it has always existed, since they have, and will, until the day they die. They only need to notice it, under their own hand, in order to feel the orienting function it can serve. Tell the client that there may be times in their life where they "forget" about the beam. They may, even "turn their own back" on the beam. They may be doing behaviors off to the "other side" of themselves, like substance use. But the comforting thing to point out to the client is that their hand has never wavered. They need only to look, to orient back to the beam to notice that it is there. No amount of behaviors off to the side of, underneath, in spite of, against, etc. takes away from the comforting, solid, constant self. This sense of self that remains constant, and is a core place from which ones "beingness" emanates, is self as context. The goal with the self as context beam is to highlight that awareness of it brings comfort, even in the face of feeling negative thoughts/private events/bodily sensations. Many clients are comforted by this type of "constant self." Another way to talk about this constant self is to have the client imagine Sitting on a Beach that a part of them has been sitting on since birth. The part of them that sits on this beach, always looking ahead of them, no matter whether the tide comes in and seemingly washes over them, or is kind of out to sea, is the self as context--the aware, constant observer self that is unchanging no matter the "sea of life" washes in. Self as context can also be represented as a metaphorically "Hallway in the Mind" whereby the hallway stretches into eternity and there is an unfathomable number of "rooms" which represent "content" areas in a person's life. The hallway is the overarching, meta context in which all "rooms" of content exist. It is important to highlight that self as context, while comforting and steady, is not simply the product of all the "positive" parts of oneself. Demonstrate the balance and completeness of self as context through the Box of Marbles metaphor. Have

the client imagine that thoughts/feelings/experiences/memories (etc) that they have experienced throughout their life are differing colored and shaped marbles (for example a "big steely," or a "bright red one.") Have them imagine and describe some of them. Have them include the "not so pretty" ones--e.g., the black ones, the ones with chips in them. Ask the client to imagine that they have the coolest container (bag or box) for their marbles ever. Have them "decorate" it in session for you, by imagining the shape and color of it. Tell them that the bag or box is "themselves" or the self as context in that they are the holder for all the marbles. Have them imagine how they have their name represented on the container. Ask the client to imagine putting the infinite number of marbles that represent their life into the bag/box. Ask the client if they are willing to a imagine a few things, for example, a) are they willing to place their own hand in there, swirling it around, feeling the warm and cold/good and bad/life and vitality, extraordinary hurt and gain of a human life? b) are they willing to hold the box/bag on their lap, especially now that it holds things that are imagined to be "less desirable?" and importantly, are they c) willing to let me see the box too, put my hand in there maybe? Discuss with the client thoughts/bodily sensations this exercise brings up for them. Validate fears related to "holding" difficult private events. Have the client notice and become aware of their own experience of "self as context." Discuss this awareness in terms of the ultimate acceptance, which is acceptance of self. 5. Acceptance. Discuss with the client the powerful nature of a stance of acceptance. Describe how willingness to experience self as context and to distance oneself from self as content can elicit a process of acceptance. The very movement of being willing to "hold" the sum total of all that one is, an opening to awareness of all of the things evaluated as goodandbad in our lives is in and of itself the process of acceptance. As noted before, acceptance is not a destination; but rather a process in motion. Ask the client if they are either willing to write something on their body, or on a piece of their clothing. Ask them if they will write the words "I am" on themselves. The client can also write this on a piece of paper and "carry" it; but it is even more salient if they write it on themselves, in effect, "wearing it as a piece of their skin." "I am" is the shortest sentence in language, and self as context is represented by that statement. When we add another word, even a small, little third word, then we step over the line into self as content. "I am," is what it is, the context from which all else unfolds.

Session Seven Session Targets: A) Interpersonal relationships and values B) Flexibility C) Control as a problem/Letting go/Coping with urges D) Acceptance 1. Check In. Check in with the client. Did they have any thoughts left over from last week? 2. Interpersonal Relationships/Values. Remind the client about the Values Highway from Session Four. Ask them to recall what values were related to relationships with other people. Most individuals will have expressed within their value set some version of wanting to connect with, or be important to, other human beings. Discuss with the client how improving interpersonal relationships can maximize and expand a vital life. Have the client draw a circle with a big arrow attached to it that represents a gauge with a meter on it. Tell the client that this is a Matter O' Meter and that you want them to represent based on the direction of the needle where differing interpersonal relationships fall. Discuss the process of mattering and how if we develop interpersonal relationships based on getting our own needs met, asking for needs, learning to be emotionally present, and responsibility to others, we are opening opportunities for ourselves to grow. Discuss with the client what it is about differing relationships that "matters" to them. Ask them to detail how the relationship matters and how they can go about expanding the relationship. Situate the entire conversation within the scope of a valued life direction which includes strong interpersonal relationships with others. If the client does not have interpersonal relationships falling within the scope of a valued life direction, have them discuss the Matter O' Meter in terms of what is represented on it, and how not valuing interpersonal relationships might be the ultimate avoidance move that is rooted in fear. Discuss with the client the notion of flexibility. Address the notion that sometimes we can become rigid the ways in which we engage the world and other people. Introduce the metaphor of a Social Dance, asking the client to imagine both dancing with someone they are close to and have relatively little problems "connecting" with, and dancing with someone they do not. Have them describe the differences between the imagined experiences. Highlight how a smooth, fluid dance includes trusting the other partner's movements, asking if you want to turn a different direction rather than simply doing it, keeping eye contact rather than looking at the ground, and accepting changes your partner might make through compromise. Address the difficulty we can have when we try to "strong arm" a social partner. Describe how flexibility is one way we can learn to stay aware and to accept. Situate the metaphor in terms of a valued life direction and as a "stance" or skills move the individual can keep in mind as they are negotiating interpersonal relationships.

Another way to express flexibility to the client is through the One Note on the Piano metaphor. Ask the client to imagine that upon meeting other individuals we are confronted with "accompaniment music" in that each person has a short, "personal score" of music which accompanies them everywhere. Upon meeting other people, along with the first physical impression we receive, we are also treated to listening to their own "personal musical score." Ask the client what type of music would be their accompaniment. Would it be complex, abstract, loud and clanging, soft and lyrical? Would the client want a structural component of the song to always remain the same but to be open to change based on context? Discuss the difference the client would feel if they met an individual whose "score" was one note plinking on the piano in a constant noteplink. plinkplink in contrast to meeting someone with an arranged, complex, piece. What kind of person does the client want to be? Do they want to be flexible in terms of situation? Do they want to be more fully complex? Discuss how being open, aware, and flexible can enhance the value of developing and maintaining strong interpersonal relationships. 3. Control as a problem; Letting Go/Coping with Urges. One important target of flexibility stretches beyond interpersonal relationships and loops back to core issues related to control agendas. Discuss with the client how flexibility can serve to develop and maintain acceptance techniques which weaken the need to control thoughts and urges. Ask the client to imagine old troubling thoughts, bodily sensations, and urges to use as bullies on the playground. Have the client discuss the form and function of these thoughts/urges. Have the client modify their response to the bullies e.g., have them sing/sound out phonetically, or use silly voices to talk to the bullies. Have the client notice how a simple change in voice or slowing down of speaking functions to create a distance between the bully and the individual. This type of move also demonstrates how flexibility in responding can offer immediate reinforcement. Here, the client is learning that their mind and thoughts per se are not their friend, but rather their own experience can be their friend in the face of bullying thoughts. Discuss how being flexible in the face of such bullies allows an opportunity for a differing response. These differing responses function as ways the client can learn to cope with urges to use or the onset of odd cognitions. Tell the client that engaging old change agendas (such as standing up to the bullies by engaging in substance use) are metaphorically like a Rumpled Old Shoe in that they are mighty comfortable, seemingly working at the time, but clearly not effective in the long run. Indicate that perhaps it is time to do something different and place ones foot in a differing shoe. Putting the foot in the old shoe is the same response that the person always does. Flexibility offers a differing, fresh perspective from which to live life and to limit engaging in old traps. 4. Acceptance Discuss with the client the nature of acceptance as a process, not an outcome. One does not arrive in acceptance, as a destination, although the culture may have us think so. Acceptance may seem like a thing because of the tricks of verbal languaging about it. However, the true nature of acceptance is an elusive

blend of awareness, balance, and willingness. Psychologically, it connotes an active taking in of an event or situation (Hayes et al., p.77). Discuss with the client what acceptance means to them. Introduce the Lighthouse metaphor. Have the client imagine walking around the outside of a lighthouse in which they are literally bathed in the beam of light that it is emitting as it circles. If they chose to simply notice the light around them (e.g., the context /experiences they have had) their life is continually illuminated. If they chose to look outside their experience (outside the light) then they lose their path. Discuss this in terms of finding acceptance of self through orienting to experience as a guide.

Session Eight Session Targets: A) Wrap up on ACT targets B) Saying Goodbye 1. Check In. Check in with the client. Did they have any thoughts left over from last week? 2. Saying Goodbye. Discuss with the client how they feel about ending treatment. Allow them to express their grief, dissatisfactions, regrets, satisfaction with themselves or you, and the benefits they have felt. Tie the client's sense of success to willingness, commitment to action, and values. Honor and discuss your experience of working with the client. Discuss their impact on you. Do a global overview of the major ACT targets. Focus on 1) noticing and distancing oneself from thoughts, 2) noticing and following values, 3) action based on values and not symptoms/thoughts, 4) successful working in adaptive domains--e.g., medication compliance, reduction or cessation of substance use, 5) and how the above can be used as strategies for relapse prevention. 3. Spiral Staircase metaphor. Use this metaphor to illustrate the connection between all the above components of ACT. Have the client draw a line representing a Spiral Staircase. Tell them that the line represents another version of the Beam of Self as Context. Although the beam is always there, the central and universal, unchanging part of us, it can often feel twisty. Have the client imagine walking up this staircase, with one hand on the smooth wood of the railing. As they imagine walking slowly up the staircase, discuss with them how the turns will feel. How will, given the context of "movement" we all feel as our lives take differing directions, continue to stay focused on the wood under their fingers, and in the real sense, stay focus on "themselves?" Have the client add another line to their spiral squiggle that parallels the line exactly, so now there is a fully formed, thick, staircase. Have them place steps in the staircase. Ask them to write differing "content" areas of their lives that will be hurdles or barriers for them to walk up. Talk about how successful working related to these content areas can be the orienting guide for them as they walk their path of life. Have the client draw hand railings up the sides of their staircase. Have them write on the handrails the values they have unearthed through the ACT therapy. Ask the client to write along the handrails the values that will help guide them, acting as both supports and boundaries--as that is what the function of all good railings are, to be both supportive and to provide boundaries. Have the client add goals hanging off to the sides of the hand rails, representing mini-goals they would like to make as they journey upwards. Make the point again to the client that values are the context in which we live our lives, and goals are behavioral landmarks along the way.

Have the client turn the paper sideways. Now the "spiral staircase" looks suspiciously like our River of Thoughts. Have the client write some of the river of thoughts they are experiencing right in the moment in session on top of the "content steps" they have written. Encourage them to also place chronic, recurring thoughts that they often have between the lines as well. Describe for the client how this drawing is like life in that we are all walking a path. We are all facing struggles in content areas which feel like "big steps." We may even feel like there are places where steps are actually missing along the way, places where we feel we might fall. Show the client that the thoughts they have written over the "content steps" are the real traps. Describe how "getting trapped" really means as we move forward in life, we get mired along the staircase and entrapped or enamored of these thoughts. We become trapped when we try and ignore, modify, change, or eliminate them. They are simply the river of thoughts, however, flowing up and down our staircase, flowing over our content steps. The main point to express to the client with this metaphor is that if we a) keep our hand firmly on the self as context beam, b) learn to notice workability as a strategy to get over those difficult "content steps", c) keep an attendant eye on the hand railings that represent our values providing context for the journey, and d) notice and distance ourselves from "buying into" the river of thoughts flowing up and down the staircase covering our content areas, values, goals, and sense of self, the path of life will be much smoother and we will be much more prepared to walk this staircase of life with acceptance, commitment to action, willingness, flexibility, and vitality. Have the client take the paper with them to remind them of what they have learned.