Step 2r Ac ceptWhat You

Cannot Ch ange

We cannot control the wind; we can only adiust tbe sails.-Kahlil Gibran

'$'n
the previous chaptegwe asked you to look at your life and get in touch with what you want to
".il"standfor. We askedyou to assesswhether you'reon a life coursethat's in keepingwith your "true
north." Sometimesthis rype of self-inventoryrevealsthat you're quite far off coursein one or more
areas.Remember,this is not the time to start beating up on yourself!Instead,take a deep breath and
call up somecompassionfor your very human predicament.In the remainderof this book, we'll teach
you a variety of skills for making values-drivenbehaviora daily reality in your life. This is the antidote
to depressioncompression.
In part 1 of the book, we explainedhow depressioncan be causedby emotional and behavioral
avoidance-consciouslyor unconsciouslyacting in ways that insulate you from painful situations-
Somerimes,avoidancefunctions to preserveyour limited energy;other times, it's the result of dealing
with the overwhelmingfeelingsof isolation,worthlessness, and helplessness
hopelessness, that charac-
terize depression.However, the paradox of depression(and avoidance)is that strategiesof avoidance
and withdraw al actualLystrengthen depression.
 TZI
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e8ueq3]ouuel lol +eq6 ldatty :7 de15
 Workbookfor Depression
& Acceptance
The lYindfulness

dilemma won't suddenly disappear becauseyou accept it, but acceptancedoes put you in a position to do
something other than dig a deeper hole. It gives you a chance to check your values comPassand make a
new move toward your "true north," Practicing acceptanceis extremely difficult when you're confronting
personal pain, but the alternative is to struggle with things that cant be controlled. This struggle not only
exhausts you emotionally but also worsens your personal pain and harms your overall health.

ffi Bill's Story

man with chronicbackpain and depression.

Bill is a ffty-one-year-old He injuredbis back
wbiletrJtinga pallet on thejob aboutfiJteen)rearsago.He returnedto work after two
monthsof leauebutfound tbat bis backpain was toointense for him to continuebis work';
He quit hisjob andfled for permanentwork disability,but his clairnwasdeniedafter an
independent medicalexaminerdeterminedthat therewasno evidence of a permanentback

\ injury. Neuertheless, Ttainon a daily basis.He wasofereda

Bill continuedto experience
vocationalretrainingoptionby tbe statebut declinedbecausebe didn'tfeel he couldwork'6t
anyjob witb all tbepain he had.
with severalsurgeons
Bill consulted and underwenta sytinaldiskfusion tbat initially
belpedbispain but euentuallyleft bin with evenworseytain. BiIlfeelsthat bis doctorshaven't
takenverygoodcareof him. He wasprescribednarcoticpain medicationabouttenyedrs
ago.Now he'sdependent a lot of pain. His currentdoctorbas
uf)onit but stillexyteriences
his dosage,
refusedto increase and Bill isfurious that bis doctorisn't helpingwitb thepain.
bispain as a burning,stingingsensation,
BilI describes like someone is putting a needlein
radiatedown bis right leg wberebe exyteriences
his back. His pain sensations and
numbness
tingling.
Bitl'sdaily routineis to spenda lot of time at bomelying on tbe sofa,as thisgives
him somerelief.He doesn'treallygo out mucbanymorebecause uprigbtactiuitytendsto be
associated with pain. He usedto go to churchwitb bis wife a coupleof timesa week,but
he stoppedgoingafter be had to leauea churchluncheonbecause oJa pain attack.There's
Blll'swiJecomplainstbqt he doesn'thelparoundthe bouse
a lot of tensionin tbe housebold.
qnd tbat he'sshort with ber and tbeir kids. Tbeydon't bavemuchintimacyanymore'as
is painfulfor bim.
intercourse
his depression
Bill belie'tes to
is causedby his cbronicpain. The morebe struggles
controlbispain, the moreangry and irritable be tendsto get.He thinksabouttbe day he
burt his backand wbetherbe couldhavedonesomethingto ?reventbis injury. He doesn't
seemucbhopetbat bis ttfewill turn aroundunlessthepain is somehoweliminated.He's
disappointed and hefeelsbad whenbeyellsat
in himselffor not beinga goodbreadwinner,
befeelsbis
bis kidsJor no goodreason.More tban once,bds thoughtof killing himselfbecause
family would be betterof witbout him.

L22
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 & AcceptanceWorkbook for Depression
The lYindfulness

' 6 ' B ' l ' S : l o r l u o l : 0 2 ' '6911' v l ' € l ' ( l ' l l ' 9 ' v ' t ' z ' l : e ) u e l d e f ) v : ^ o >
Bt'Lt'91'0t

Debriefing.Did your answersdifferfrom those in the key?Billhassome controlover quitea few things.He
can influencethe amountof time he spendson the sofa,hisattendance at church,his participation
in daily
exercises, hisbehaviortoward hiswife and children,and hissexualrelationshrp
hisuseof narcotics, with his
wife.And he couldchooseto challenge hisassumptions abouthispainandtry vocational retraining.
Do theseanswerssurprise you?Takea closelookatthe eventsandexperiences thatBillhasno immediate
controlover:not justphysicat but alsohisspontaneous
sensations andmemoriesrelatedto
feelings,
thoughts,
history.Beingin paincauses
hispainandhispersonal including
privateexperiences,
predictable negative emo-
thoughts,andimages
feelings,
tionsandthoughts.Unpleasant showup in the momentfor allof us in response
or avoidthem.
to pain-and theyshow up morewnen we try to suppress

-l-"-i:r=ffi_''

WHAT MUST BE ACCEPTED

Many difficult life situations, like Bill's experience of chronic pain, make the process of sorting out what
one can and cannot change challengingr an unwanted divorce, a child with a serious illness, the death
of a close friend, the diagnosis of a serious health problem, and so on. These types of painful circum-
stances may come into a person's life without warning. However, when you respond with avoidance
and withdrawal in order ro protecr yourself from unwanted thoughts, emotions, or memories, you lose
control over your behavior. By trying to wash your hands of responsibility for any asPect of the situa-
rion, you're likely to lose insight into which aspects of the situation you actually can exert some control

\ over. In the meanwhile, you may be struggling to exert control over aspects of your human experience
that cant be controlled, including the following:
,/

N Spontaneous feelings

w Spontaneous thoughts

$$ SPontaneousmemories

N So-" pnyrical sensations

N An obiective eveflt, act of fate, or extetnal stressor

N Other people's behavior

s Past events and personal historY

97r
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i

i
i
The Mindfulness
& Acceptance
Workbookfor Depression
I

i Itt important to understand that your level of acceptance can vary from moment to moment Since
i
i
acceptance is an action and not a result, it never remains at a constant level. Think of acceptance as a
I
Ii
stance you try to adopt rather than a posture you maintain continuously- You might think of it as a
difficult yoga pose. Most of us can learn to come close to that pose, but few of us could maintain it for
an extended oeriod of time.
a

Acceptance
Is Nof Resignation
Pleasedont mistake acceptancefor resignation, or giving in to a life of misery. This would be akin
to telling a personto just get usedto being depressedfor the rest of his or her life, somethingwe would
nevercondone-For example,we would neverask an abusedwoman to acceptthat she'll be beatenby
her husbandon a regular basisfor the rest of her life. This is a situation in which shehas somecontrol
over values-based
behaviors.If shevaluespositiveintimacy,then shedoeshaveoptions.She can stay or
leaveor do somethingin between-What she has to acceptis that if she does nothing, she'll probably
continue to get the negativeresults in her relationship that she! been getting.

Acceptance
Doesn'tMean You'ueFailed
Acceptanceis not an admissionof failure or defeat.When you give up the strugglewith unwanted
private events,you'resimply givingup somethingthat has neverworked. This form of acceptancesimply
means that you recognrzethat this sttategy isnt going to work. This is akin to dropping the shovel,
and it's actually a prelude to success-to building a more fexible and effectiveresponseto the situation.
Notice that this meansacceptance
and the workability yardstickare closecompanions.When the work
ability of your life is low, you not only haveto acceptthat the readingis low, you also haveto acceptthat
what youve been doing isnt working-and then you haveto be readyto acceptwhat showsup between
your earswhen you stop engagingin unworkableresponses.

AcceptanceDoesn'tMean ToleratingPersonolPain
Another common misconception about acceptanceis to confuse it with toleration. Think of the
'with
distinction between toleration and acceptance this way: Toleration is a form of acceptance strings
attached-" You're only willing to accept distress or suffering up to a certain level and no further. We all
practice toleration when we go to the dentist: You tolerate the pain and discomfort of that big needle
or the drilling becausethe consequencesof avoiding the dentist will eventualLybe far worse than what
you have to go through in the present. At the same time, you may have an evaluation of pain that saysit
isnt acceptableto have pain over a7 on a scale of 1 to 10. So if the pain goes over thatlevel, you'll alert
the dentist or take action to control the pain, even if it includes leaving the scene! Or you may accept

t26
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e8ueq3louuel nol ]pq6 ldatry :1 da15
The Mindfulness& AcceptanceWorkbook for Depression

rehearse these sorts of acceptance statements, they'll be at the ready to counteract yout reactive mind
and allow you to stay in a posture of acceptance.

EXCESSIVESUFFERING
In ACT we make an important distinction between suffering and excessivesuffering. Together, suf)
fering and excessivesuffering make up your entire personal experienceof a negative event,situation,
or interaction in your life. Suffering is the original discomfort you feel in responseto an actual event.
Although it doesnt feel good, it's a natural and ultimately healthy experienceif ir isn't suppressedor
avoided.Excessivesuffering, on the other hand, is the pain you ger when you struggle to control, elimi-
nate, or avoid your original suffering.
In Bill s case,he's creatingexcessivesuffering for himself by avoiding important aspecs of his daily
life in the name of managing his chronic physicalpain. Consequenrly,he experiencesthe excessive
suffering of a strained relationship with his wife and kids, as well as chronic anger, krrtability, and
negativethoughts. Whereas suffering is natural and often provides important signals that can help us
make decisionsthat promote health and well-being,excessive
suffering leavesus feeling trevmatized and
emotionally exhausted.If given the choice,most people would gladly return to their original suffering
if they could somehowwalk away from the excessivesuffering they'vebecomeentangledin.
 The Mindfulness & Acceptance Workbook for Depression Suffering and Excessive Suffering

Exercise: Suffering and Excessive Suffering

This exercise will help you assess how suffering and excessive suffering are playing out in your life. As you fill out the worksheet below,
first take a few minutes to identify a difficult situation you’ve recently experienced. Try to be as specific as possible when you describe it.
Next, describe the original suffering that’s a natural consequence of this problem. Then describe how you might be generating excessive
suffering in this situation. Describe the behaviors you’re engaging in and the type of excessive suffering you experience, such as anger,
resentment, guilt, shame, damaged relationships, and so on. Finally, consider the total amount of both types of suffering to equal 100
percent, then divide those percentage points between your original suffering and your excessive suffering; the total should add up to 100.
This will allow you to see where most of your pain is coming from. You may wish to copy this worksheet or print out blank copies from
the CD to analyze other issues.

Suffering and Excessive Suffering Analysis

Difficult
situation

Score
Original
suffering

Excessive
suffering

© Kirk Strosahl and Patricia Robinson/New Harbinger Publications 2008

 The lYindfulness
& AcceptanceWorkbook for Depression

MXtgJSSUFFERING AND EXCESSSVE

'AY
butsfl,utttl\u AI\dALYSTS
YFFFN TA T,/-

Difficult I hat/o chaonipPa,in a4^d' cn /t d,o flwrfuh4g.y I uaad,,to- d,o:

situation
Score
Original a,nd/ I feel,,nd, a,n"fufn vtt ann , by 2 0
I h^^,t/taJ/vnott allt of &ve,,fr,vne-r,
suffering vwytnal>tl,tty ta- d,o-fl\plflnlry I uAed/to- dDl
Excessive I'rw u'nnd)in4,to-acrppt all/ of fue' aw@flnlryfuiEwxvLws
-[ww dnwp, B O
suffering fu vnez;tnfund, I rrw,vni,nafuiabout I'w-z bea,v rnt*re,a"A,at Uy
datmw a'vdt vny enaployetr i,w &is uil^olp' ni4htvna.rez I'tv W vny
fen'ry about vwyd,t*al:ilrcy th/r"d" tuv&wwat of vny redLrwtD-wo*z
A^d.,,u)ol,tt of dl/, I'v? all,oiled/ vny pain to i,nfufurct wtflv rdan n4' W
my wL{etan"d/kid.tflr'et way I'd/lil<e't4 tu4dr I'vn, a.{taidtfu,e'y dnn,t
Lovet vnu a'ywww{et
ti

Review. Bill's responserevealsthat what turns an unfortunate but not uncommon life situation into
somethingtraumatic is the stancetaken toward suffering.Again, it's the paradoxof avoidancerThe less
acceptingyouare of your suffering,the more you try to suppressor control it; however,the more you
try to suppressit, the more traumatic the resulting excessivesuffering is. Consider this: If you could
learn to stop creatingexcessivesufferingfor yourselfbut to do so you had to let the original suffering
be there, would you be willing to make that trade?If this interesrsyou, read on and we'll show you
how to make this deal.

)
WILLINGNESSI AN ALTERNATIVE TO AVOIDANCE
In ACT the conceptsof willingnessand acceptance are consideredto be bedfellows.Think of willing-
nessas choosingto enter a difficult situation with the intent of using a posture of acceptancerather
than a postureof avoidanceand suppression. Willingness allowsyou to exposeyourselfto what you are
aftaid of. Acceptanceis what you do when you get there.Willingness is a voluntary,intentional action;
it must be, becauseyou'resmart enoughto know how to avoid situationsyou d rather not experience.
Usually,low levelsof willingnesstend to correspondwith high levelsof excessive
suffering.

130
 The Mindfulness & Acceptance Workbook for Depression Willingness and Acceptance Plan

Exercise: Willingness and Acceptance Plan

This exercise will help you develop a willingness plan that you can implement in your daily life. It builds upon the results of the previous
exercise. The goal is to begin to shift points from the excessive suffering category to the original suffering category by practicing a stance
of willingness and acceptance in situations you’ve identified as producing a sense of excessive suffering.
First, copy your descriptions of your original suffering and excessive suffering from the previous exercise onto the form below and
record your percentage for each type of suffering under Day 1. Then, at the bottom of the worksheet, describe specific behaviors you’ll
engage in that demonstrate a posture of willingness (this usually means choosing to enter the situation) and acceptance (simply allowing
what shows up in your awareness to be there). It’s helpful to include a description of what you can and cannot control in this situation so
that you’re clear on what you must be willing to accept.
After you’ve implemented the plan for a week, come back to this exercise and record your new percentages for your original suffering
versus excessive suffering. Hopefully you’ll see progress. If not, it may help to talk this over with a friend. Sometimes you just need more
practice; or it may be that you need to revise your plan.

Willingness and Acceptance Plan

Score
Day 1 Day 7
Original
suffering

Excessive
suffering

Willingness
and accep-
tance plan

© Kirk Strosahl and Patricia Robinson/New Harbinger Publications 2008

The Mindfulness
& AcceptanceWorkbook for Depression

Debriefing.What resultsdid you seeafteryourflrstweekofpractice? Did someof your percentage points

shiftout of excessive
suffering?
lf not, don't be afraidto experimentwith differentstrategies.
Bill'scompleted
worksheetappearsbelow so you canseehow this processplayedout for someoneelse.

+1. ^
LI IC

eve
ofc
'-b'

tsTLtS WXLLThIGT.{ESS
AND ACCEPTAI{CE PLAI-{ (Alt

you
Score
taD
Day L Day 7
nor
Original I h.4tt/talxwott alL of d4"e'fr,vn?,a,n"d/I {edt sa"d"a'nd/ 20 35 ino
suffering fru,ttratun'Iry ^y t^a.lrtw fn- db-Awrd,nlwl uaed/to
d.o. cor
fac
Excessive I'rw u.nnd)i,rq<to- ar,ce+t alL of ev, a.NftiLd,tu^gteis BO 65
pq"irvllns dbl,\Btto-rnez;truAnd,, I ru,yni,na.btabout-l4,ol.) nu
suffering
I'vsbe,e.yvyni,fieateA,'W dn$ow a,nfu vny ovnpl,oyortn d:v
thiswholp' nt4Wvna,rcz.I'vsW yryl f"a.ry d>out vny Pa
df,talril.lty te,n"dt L4'vfu.e/wayof vny returvvto-wo&r.
thc
And.,,wovttof al.l/, I'vs ilJ..owef, vntl pa,ixvfa Afu,rfeyw
wtfu, rclnfr,vr4,to rny wfu andrWd.tewrway I'drlikp'tq
a,nd.,I'rnt afi.ai"d/d,\et dnr"tl,ove vne a,nyvnop.
Willingness IA atfund,'w d,a*for penptzwtflv clwonir-,,pailve1a,t vny d,odor ypxD'y1/1./-
and accep- Atflwft,ytt vwennn* IA yead, vny vil,trc* tfu.fume,yflVto-fup/
rnen"d.,edz
e.nfi,yel c]a&&
tance plan

Review.Bill had seriousdoubtsas to whether a classcould make a differencefor him, bur he decidedto
give it a try. Though it would be difficult, he decidedto try ro shift his excessive
sufferingnumbersby
statinghis valuesto the classat the first meeting-Not only would this reafirm his values,it might also
createa greatersenseof committing to them, as is often the casewhen we discloseour goalspublicly.
He receiveda gteat deal of positivesupport from others in the class,and they were very interestedin
his experimentwith his willingnessand acceptance plan. This reminded Bill of how he'd once been a
leader and creativethinker at his job-

r32
 The Mindfulness & Acceptance Workbook for Depression Willingness, Depression, and Vitality Diary

Exercise: Willingness, Depression, and Vitality Diary

When you begin studying your willingness level, you will notice that it vacillates minute by minute. However, the realities of contempo-
rary living make it very difficult to stay focused on such intricacies in the moment, even though doing so is an important element of vital
living. Because of this, you’ll need to practice some type of observation of your willingness levels on a daily basis. The daily diary form
that follows can help you in this regard. You may wish to make copies of this blank form so you can continue to keep the diary over time.
(Alternatively, you can print out fresh copies from the CD.)
Complete the form near the end of each day, when you can reflect on the entire day to come up with your responses. You’ll assess
your willingness in the column labeled “W,” your depression in the column labeled “D,” and your vitality in the column labeled “V.” Assess
each using a 1 to 10 scale in which 1 means none and 10 means extremely high. First rate your willingness to experience unwanted and
possibly distressing experiences over the course of the entire day. In the notes column, describe any factors that may have contributed to
higher or lower levels of willingness. Next, rate your depression level and, again, describe any factors that pushed your depression level
up or down. The third rating is the most important. Assign whatever number best reflects the extent to which you felt your activities
were purposeful and meaningful during the day and, in the notes column, describe anything that contributed to a higher or lower sense
of vitality. Make particular note of any spontaneous, natural moments when your willingness or vitality levels were high. At those times,
what were you doing that elevated your willingness or vitality?

© Kirk Strosahl and Patricia Robinson/New Harbinger Publications 2008

 The Mindfulness & Acceptance Workbook for Depression Willingness, Depression, and Vitality Diary

My Willingness, Depression, and Vitality Diary

Day W Notes D Notes V Notes
1

W = Willingness (1–10); D = Depression (1–10); V = Vitality (1–10)

© Kirk Strosahl and Patricia Robinson/New Harbinger Publications 2008

 The Mindfulness & Acceptance Workbook for Depression Willingness, Depression, and Vitality Diary

Debriefing. What did you see in terms of the relationship among your daily willingness level, depression level, and sense of vitality? Did
you notice that your willingness and vitality ratings fluctuated from day to day? That’s normal when you first start practicing willingness.
What occurrences seemed to spark higher levels of willingness and vitality? What factors decreased your willingness level? When you
notice factors that drive your willingness down, you might consider putting together a new willingness and acceptance plan to use when
those factors are at play.
To give you a sense of how this daily practice played out for someone else, let’s take a look at Bill’s responses. This will show you
how much information can be gleaned from doing this exercise in earnest for just one week.

© Kirk Strosahl and Patricia Robinson/New Harbinger Publications 2008

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 The lYindfulness
& AcceptanceWorkbook for Depression

ffi Bill's Journey Toward a Vital Life

When he implemented
his willingness
and acceyttance
ytlan, Bill noticedthat he enjoyedsocial
connections
witb his classmates
and that bispain levelsseemed
to decrease
wbenbe was
focusedon tbe class.He wassur2trised tofnd tbat he couldgo to a movieand sitthrougbthe
wholething without a pain episodeof hugeytroytortions
afterward,as had alwaysbappenedto
him in the earlyyearsof bis chronicpain problem.He realizedtbat be badytreviously
goneto
moviesaloneand wonderedif tbe diferencethis time was because he went witb bis wife and
he waswilling to bauepain in orderto do sometbing positivefor tbeir relationship.Bill began
to plan daily actiuitiesthat wouldengage
his attentionin areqsof his tife he wqntedto build,
includingspendingmorequality time witb bis cbildren.He found tbat he couldgo to thepark
witb tbem if he did it at the start of the day.He couldthen reststrategically
to restorehis
physicalstrengtb.
He beganstretchingregulailya coupleof timeseachday to helpmanugehis pain, even
whileacceytting
tbefact tbat he wouldprobablyexperience
painfor tbe restof bis tife.He still
struggledoccasionally
with angerabouthisfate, ytarticularlyon dayswhenbispainf.ared
uyt.However,be stuckwith bisplannedactivitiesevenwbenhe wasin pain. His relationshiyt
with bis wife improvedto tbeytointwheresbetold him be was like a new person.Bill wason
tbepathwayout of depression!

L36