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Acceptance and Commitment Therapy for Insomnia Treatment Manual

Lindsay Fletcher
University of Nevada, Reno
Adapted from
Hayes, S. C. Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and Commitment
Therapy: An experiential approach to behavior change. New York: Guilford
Press.
Twohig, M. (2004) ACT for OCD: Abbreviated treatment manual. Can be found at
contextualpsychology.org.
This is a general protocol for eight, weekly, one-hour sessions of Acceptance and
Commitment Therapy (ACT) for insomnia. Each section of the treatment will have core
intervention strategies, with additional treatment strategies listed at the end of each
section. Because this manual will not fit all clients’ needs, it may be tailored to each
particular client. Tailoring of the treatment may involve shifting components in this
treatment manual to different sessions than indicated, or adding material to support the
components that are already suggested in this manual, as well as reducing or increasing
the number of sessions, as long as the treatment is between six and twelve sessions. Only
material that is consistent with the ACT model may be added to the intervention. This
protocol is to be used in conjunction with the sources listed above. Where exercises are
not fully written out here, they can be easily found in these other sources.
In addition to the general ACT protocol, participants were taught meditation
exercises in session and instructed to practice these daily for a specific amount of time,
usually between 10 and 20 minutes, although it may be extended up to 45 minutes by the
end of the treatment. The meditation exercises began with simple concentration training.
The meditation instructions changed each week, adding awareness and acceptance of
body sensations, thoughts, and feelings, specifically targeting sleep-interfering private
events. For example, it is often easy to predict the thoughts that show up around bedtime,
such as “I’m not sleepy yet”, “I’m not going to get enough sleep again”, “I’m going to be
zombie tomorrow”, and “I can’t stand this”, and this “tape recording” can be recognized
and addressed with acceptance and defusion exercises. After the first 2-4 sessions,
meditation instructions are based on an idiographic assessment and the phase of treatment
such that the meditation exercise targeted the relevant ACT processes and content related
to the client’s situation or story. These meditation exercises are not fully documented
here, due to the range of different instructions given. However, several examples are
provided. The important point is to include a daily meditation practice that is guided by
ACT principles.
Beginning a meditation practice can be extremely demanding and clients will
often have many questions and difficulties. In order to competently address the clients’
experiences, it is imperative that the therapist also engage in a regular meditation
practice. This claim is not yet supported by data. However, other approaches with a
meditation component also stress the importance of this (MBSR, MBCT) and ACT

4/14/08

Systematic tapering was not used for this study and is recommended for future studies. 3. This includes: if the client reports plans of harming themselves or others. and it compares movement during wake time to movement during sleep. The only exceptions to this are that individuals will listen to the CDs of audio-recorded sessions for supervision purposes. 1. to be agreed upon by the therapist and client based on satisfaction with treatment progress. or reports harming a child or the elderly. Explain each column of the diary and explain that the time to sleep onset. Also ask them not to worry about the accuracy of the watch. Provide the participant with an actigraph and ask them to wear it all the time. don’t purposely move around at night so that it “knows” you are awake. This is just an estimate of sleep time. Explain that it is recording their movement. confidentiality must be broken according to the ethical codes of the American Psychological Association. Make sure that you have the clients phone number(s) so you can reschedule in case the client does not attend the session. Introduction Make sure the client understands what he or she has agreed to participate in. Measures Ask client to fill out pretreatment packet. The participant will be attending between six and twelve sessions of therapy. e. come up with a plan for tapering off of them. At the end of these six to twelve sessions the client will be expected to attend a post-treatment assessment and follow-up assessments one and three months later. In addition.g. so that it can most accurately record sleep time. then continue to reduce the dose each week until they are no longer using them. Pretreatment Assessment. Give them a sleep diary to take home. The sessions will occur every week. 4. and how to deal with this issue should be considered at the outset. Allow the participant to ask you questions concerning the study. download the actigraphy data and return the watch to the participant. Each week. 4/14/08 . It follows that including a meditation component then requires that the therapist practice meditation. and time spent asleep must add up to the time spent in bed. generally at the same time on the same day. Use of sleep medications is widespread among insomnia clients. 2. Also ask them to record their medication use each day. Termination Schedule next appointment or commit to calling within one week. Discuss limits to confidentiality Explain that everything that occurs in session will remain confidential. such as reducing the dose by half after the first two weeks. Is it the client’s goal to stop using sleep medications? If so.trainers claim that you must be willing to do ACT with yourself as the therapist in order to be an effective helper for someone else using this approach. time spent awake. The client is expected to attend all sessions and to contact the therapist if he or she cannot attend.

Review medication use for the week and discuss tapering if appropriate. So what I would like is a period of time . ask the client to fill it in as best they can. 2.” 4/14/08 . confusion. you will know it and we will both see it in your life. things may look worse before they look better.6 sessions. is that if you do not really engage in these 6 sessions you will not really know whether this treatment is useful or not. and so on. It is like cleaning out a dirty glass with sludge in the bottom: the only way to do it is to stir up the dirt. the client should be warned of this and agree to participate in the entire treatment and not to judge the treatment impulsively.Session 1. can be difficult and frightening. for some. Make sure that it is filled out completely. Assessment and Creative Hopelessness 1. It is like exercise: sometimes good things hurt a bit. look over the client’s sleep diary. It is just that we can’t be sure of this on a week to week basis. It is not that it is overwhelming . we will get into fairly basic issues. Especially if we end up stirring up old issues sometimes it might look like we are going backward when we are really going forward. So some stuff might get stirred up. Orientation to treatment Address context of therapy in medical setting Acknowledge that the client came to the sleep center seeking medical treatment and what they are undertaking now is quite different from a medical regimen. Review sleep diary At the beginning of session. and for a while.even if you really want to quit. All kinds of different emotions might emerge: interest. My experience with this approach is that it can put you on a bit of a roller coaster. sadness. This is a behavioral approach to their sleep problem.” Commitment to a Course The treatment of insomnia. Therefore. “A fundamental treatment like this is best done by carving out some space within which to work. the outcomes of ACT are not seen until later in the treatment. Sludge in glass metaphor “As I said. If we are moving ahead. if there is any missing data.it is just that you should be prepared to let show up whatever comes up. anxiety. I believe that clients should hold therapists accountable: I’m not asking for a blank check. Discuss the client’s sleep for the past week and assess for degree of satisfaction. clarity. boredom. including some that you might not have expected in therapy. Let’s push ahead for that amount of time no matter what . One of the reasons that I find this important. because their doctor and I believe that their insomnia has a psychological component and has ruled out any other medical conditions that could be causing it. Also. in some cases.

and live your life. you are in the hole because you walked exactly that way. blindfolded. In one sense. Pretty soon this hole is huge. It is important that the client and therapist have a sense of mutual trust and respect before beginning work from an acceptance and commitment perspective. My job is to watch out for you and shout out directions if I can see places you might slip or hurt yourself. More. and you’re given a little bag of tools. because digging is not the way out of the hole. the therapist should also work to be warm. wearing a blindfold. and better. and better. So you try digging faster. and then I feel in. You might tell yourself. Anyway. looking down at you. empathetic. This is like what has happended with your anxiety. So you start running around and sooner or later you fall into this big hole. But all of that makes no difference. and over a little hill. and accepting. just across a valley. blindfolded. fairly deep holes. that may be true. and what might be a better path for you to take.  Ask them to describe the problem. knowing that is not the solution to knowing how to get out of the hole. More. in this metaphor.” etc. in this field there are countless widely-spaced. because unbeknownst to you. Now one tendency you might have would be to try and figure out how you got in the hole--exactly what path you followed. Two Mountains Metaphor “It’s like you’re in the process of climbing up a big mountain that has lots of dangerous places on it. “I went to the left. But it doesn't work -. However. and you’d gone somewhere else instead.” 5. Creative hopelessness: Man in a hole metaphor “Imagine that you’re placed in a field. So maybe you stop for a while and try to put up with it. and caverns.3. Probably what you would do in such a predicament is take the bag of tools you were given and try to get out of the hole. halls. You’re told that your job is to run around this field.you are still in the hole. different. I don’t have to know anything about exactly what it feels like to climb your mountain to see where you are about to step. or with a different style. In addition to providing and gathering the necessary information during these sessions. It is more and more elaborated. it only makes the hole bigger. Assessment Obtain a picture of what insomnia looks like for this client. Furthermore. so now you’re in this hole. It has multiple rooms. different. If I’m able to help you climb your mountain. or with bigger shovelfuls. Find out what they find the most distressing about this problem and what it specifically disrupts in their life. Alliance Building Creating an alliance is an important part of therapy. Do they have more trouble getting to sleep or waking up earlier than desired?  Any pattern to better or worse sleep?  Why are they participating in the treatment? How will getting control of the insomnia make his or her life better? 4. you might have fallen into another hole anyway. But I’m not able to do this because I’m standing at the top of your mountain. but pretty soon you notice that you’re not out of the hole. It is 4/14/08 . So you dutifully start digging. it’s because I’m on my own mountain. Now just suppose that the tool you’ve been given is a shovel. even if you had not done exactly that.

It's hopeless. If you need to dig. Instead of learning to sleep better. and the knowledge that nothing has worked. It'd only make it worse. 6.bigger and bigger. it wouldn't work. The emphasis in this simple meditation is on simply noticing the struggle and developing present moment awareness. You’d only try to dig with it. You absolutely can't dig your way out of the hole. Nothing I can say right now would help ease the difficulty of what you have to do here. But within the system in which you have been working--no matter how much motivation you have.” If client asks for the way out of the hole. Introduce the idea that sleep is not the goal for right now and invite them to accept their sleep functioning as it is right now. while seated in an upright position. That’s not to say that there is no way out of the hole. The problem is not in the tools.” Clients are instructed to continue this practice at home. So you come in here wanting a gold-plated steam shovel from me. it is digging. Your job is to accept that you are in one. And that is a very difficult and bold thing to do. 7. you've got a perfectly good tool already. even if you were given other things to do. start over at one. You can’t do anything else until you let go of the shovel and let go of digging as the agenda. This is what meditation practice will help them to learn. Meditation: mindfulness of breathing exercise with counting “Silently label each out-breath with a number. No fooling. imagine letting those go for now and just accepting what is. and to let their partners or roommates know not to disturb them during this time. You need to make room for something else in your hands. That is what you have been doing right along. And I can’t really reassure you on that. It’s in the situation in which you find yourself using them. for 10 – 20 minutes each day. Do they have expectations for treatment? If so. Letting go of it looks as though it will doom you to stay in the hole forever. Well. I can’t give it to you and even if I could I wouldn’t because that’s not going to solve your problem. In the position you are in right now. The shovel appears to be the only tool you have. without trying to fix it. starting with one and building up to ten. I has become a central focus of your life. The things you’ve been taught to do aren't working although they may work perfectly well somewhere else. This is very important for learning to persist based on a commitment rather than stopping due to discomfort. Homework  Sleep diary & meditation form 4/14/08 . You know that sense you have that you are stuck? And that you came here to get help to fix it? Well. Tell the client to note any strategies they use to pick up the rope on their sleep diary to review for next session. And in the system in which you are working. This is not a trick. you are stuck. Have you suffered enough? Are you ready to give up and do something else?” Relate the use of shovels and digging to an ACT conceptualization of insomnia. The problem is not the tool -. there is no way out. If you were given a ladder right now it wouldn’t do any good.it is the agenda. Ask them to choose a place where they can sit regularly without being disturbed. the more difficult it is to sleep. the focus will be learning to rest. And ladders make terrible shovels. But what I’m saying is that it can’t work. After ten breathes. The harder they try to go to sleep. say something like “your job right now is not to figure out how to get out of the hole. You know all this hasn’t worked. Your best ally is your own pain. Ask them to set a timer and not to get up until the timer goes off. or how hard you dig--there is no way out.

As much as possible. In particular. “Find a comfortable position and when you are ready. Also note ratings for satisfaction with sleep. such as looking for the right answer. and very strong. Ask them to write down their observations about what “shovels” they are using and bring them to session. and medication use. Respond to this by first normalizing that this response is very common. Explore with the client how they may worry about “doing it right” in many other areas of their life and that this simply a repetitive thought that they don’t need to buy. assess for whether clients are terminating meditation sessions due to the time elapsed or discomfort. In between you and the monster is a pit. during the meditation and throughout the day. Discuss tapering medication and form a plan. 3. You are lying in bed awake. Ask clients to notice how difficult it is to simply stay present without distraction. bring to mind what that experience was like. Repeat the meditation from last week. Be sure to spend time addressing client’s difficulties or successes. Review sleep diary and meditation Examine the sleep diary for sleep time. whether at night or during the day. Now remember to the last time that you had difficult sleeping. notice where you are holding tension in your body. Continue Creative Hopelessness Discuss what the client noticed during the past week about ways of digging. particularly those that show up in session. sleep onset latency. and then look at how this is another control strategy that prevents the individual from being present to what is happening in the moment. A common experience for beginning meditators is to wonder if they are “doing it right”. The Tug-of-War with a Monster Metaphor “This situation is like being in a tug-of-war with a monster. Creative hopelessness 1. It is big. Session 2. Address any barriers to practicing daily and completing the full length of practice sessions. Meditation exercise Begin session with a mindfulness exercise. Silently label them … How do you feel in your body? Do you notice any areas of tension? If so. Recall of inability to sleep through imagery. gently close your eyes. ugly. Continue identifying shovels. it is 4/14/08 . Discuss how the meditation is going and trouble-shoot any other issues. and as far as you can tell. Review the client’s meditation practice for the week. What thoughts are showing up? … Notice any emotions that arise. time awake after onset. or use the exercise below.” Debrief: What came up? What did the client do in response? What “shovels” did the client pick up in order to control their internal experiences? 2. 4.

The hardest thing to see is that your job here is not to win the tug-of-war. Control is the problem – letting go is the alternative Walk through the following exercises to help the client become aware of their programming: Mary had a little …. “How do I do that?” after this metaphor.” 5. ask what they noticed regarding the tug-of-war? Were there any instances of “dropping the rope”? It is often helpful to notice that what they are already doing without even realizing it that works. Blondes have more … What are the numbers? Polygraph metaphor 4/14/08 . ask the client to notice any sensations in their body that draw their attention away from the breath. So you pull and pull. then feelings. you will fall into this pit and will be destroyed. Meditation Start the session with a mindfulness exercise that builds on what they have been practicing by adding awareness of body sensations and increasing acceptance of whatever arises. In addition. it seems the harder the monster pulls. Sessions 3 & 4. The therapist can say something like: “Well. Homework  Sleep diary & practice form  Mindfulness of breathing exercise with counting.” Sometimes clients ask.bottomless. Review sleep diary and mindfulness homework Also. Debrief: What did they notice? Did they pick up any shovels or drop any ropes? 3. The second week.. yet these are precious moments of freedom. and it appears that you are edging closer and closer to the pit. I don’t know.. so that the client is progressively including more aspects of their experience in the meditation with an accepting stance. you may add awareness of thoughts. The same instructions apply here as for counting breaths. but the harder you pull. Administer process measures (KIMS.  Notice any experiences of “dropping the rope” and write them down. It is best not to answer firmly at this point. Ask them to imagine making a bit more space around the sensation or use whatever physical metaphor seems to click for the client to become more accepting of these sensations. Your job is to drop the rope. But the first step is really to see that the tug-of-war can’t be won. Control is the problem … acceptance is the solution 1. 4. If you lose this tug-of-war. TCQ-I and AAQ) (Session 4) 2. We often don’t pay much attention to the moments when we are at peace and not distracted by thoughts. and that it doesn’t need to be.

" etc. memories. such as anxiety." Now what if one day you get tired of that and say. pretty much. they don't even have to tell you. However. telling you what you have to do. when they eventually do show up. and you wrestle with them. they're real strong. "You've got to turn left. Now the trick about the whole thing is this: The power that the passengers have over you is 100% based on this: "If you don't do what we say. The deal you make is to do what they say so they won't come up and stand next to you and make you look at them. if you don't do what they say. and you go back to deal with the mean-looking passengers. It's as if you've made deals with these passengers. the mind can be like a tape running. Eventually you go back to placating the passengers. feelings. bodily states. Falling in love Trying to control positive emotions does not work either. They don't intend to leave. in exchange. etc. you're driving along and the passengers start threatening you. which means that trying to make it go away is futile and only increases fusion with these thoughts.” Draw on the client’s experience as much as possible without trying to convince them that this is so. The passengers are thoughts. it's with the added power of the deals that you've made with them in the past. “Is this what your mind is like when you go to bed/wake up early? When lying in bed awake at night. Notice now. Pretty soon. They've got knives. you just tell yourself that left is the only direction you want to turn. to try to get them to sit way in the back again where you can't see them. This is due to programming. Warm jelly donut Trying to control thoughts is also counter-productive. And plus." That's it. In other words." "you've got to go right. and other aspects of experience. "I don't like this! I'm going to throw those people off the bus!" You stop the bus. but you trade off the control in these secret deals with the passengers. and I'll do what you say. The threat that they have over you is that. The problem with that deal is that. "Turn left"--you know as soon as you get near a left-turn that the passengers are going to crawl all over you. and the deal is. The driver (you) has control of the bus. and they're dressed up in black leather jackets and they've got switchblade knives. with a highly predictable storyline. 5. Except you notice that the very first thing you had to do was stop. It's true that when they come up they look like they could do a whole lot more. Some of them are scary. where you have to go. It looks like you could be destroyed. you're just dealing with these passengers. "You sit in the back of the bus and scrunch down so that I can't see you very often. Passengers on the bus metaphor "It's as if there is a bus and you're the driver. you're not driving anywhere. What happens is. chains. they're going to come up from the back of the bus. but it just doesn't turn out very successfully. by trying to 4/14/08 . we're coming up and we're making you look at us. you do what they ask in exchange for getting them out of your life. Eventually you may get good enough that you can almost pretend that they're not on the bus at all. On this bus we've got a bunch of passengers.Use this metaphor to illustrate that control does not work for negative emotions.

make it go down." etc. No more. Be very clear I'm not saying that discomfort will go down. and so on. etc. What I am saying is that if you give up on the effort to manipulate your discomfort.” Discuss what passengers show up around sleeping. This other scale can also go from 0 to 10. [move the other hand around in front] It is really the more important of the two. It's been hidden. avoid it. whole new sets of bad feelings have shown up. then over time it will assume the level that is dictated by your actual history. But now there's also another scale. please. and control is low. 7. was this: "This anxiety is too high. change it. and you're trying hard to control this anxiety. No less". When Anxiety [or discomfort. Willingness and acceptance Two scales metaphor "Imagine there are two scales. you've actually given up control! Now notice that. guilt. to help me do that. That may be a big part of why you are here. This second scale is called "Willingness." It refers to how open you are to experiencing your own experience when you experience it--without trying to manipulate it. The "clean" discomfort is what you can't get rid of by trying to control it. the therapist. 4/14/08 . or it will be low. obsessive thoughts. These passengers can't make you do something against your will. it kind of falls out of the picture and you're left with only the "clean" kind. such as "Anger. escape it. [move the other hand up and down behind your head so you can't see it] What we have been doing is gradually preparing the way so that we can see this other scale. if anxiety does not. etc.get control. The discomfort that life just dishes up--that comes and goes as a result of just living your life--that is "clean" discomfort. That extra discomfort--discomfort over discomfort--we can call "dirty discomfort" and once willingness is high. depression. worry. unpleasant memories.--use a name that fits the client's struggle] is up here at 10. What are they saying? What is the client doing in response? What are some other options in stead of fighting with them or just doing what they say? 6. even though your passengers claim they can destroy you if you don't turn left. In the posture you're in. Sometimes it will be high. We've been bringing it around to look at it. In other words. make it go away. disturbing thoughts. what brought you in here." It's way up here and I want it down here and I want you. It can go from 0 to 10. As a result of running away. In other words you have been trying to pull the pointer down on this scale [the therapist can use the other hand to pull down unsuccessfully on the anxiety hand]. "Dirty" discomfort. on the other hand. like the volume and balance knobs on a stereo. It may also help to move ones hand as if it is moving up and down a numerical scale]. then you're unwilling to feel this anxiety. Pain vs. the Willingness scale is down at 0. the environmental circumstances in which you find yourself. It is hard to see. is emotional discomfort and disturbing thoughts actually created by your effort to control your feelings. because it is this one that makes the difference and it is the only one that you can control. it has never actually happened. because of your history. One is right out here in front of us and it is called "Anxiety" [Use labels that fit the client's situation. You don't know how much discomfort you'll have left in any given situation once only "clean" discomfort is there. suffering (what we do to get rid of pain) "We should try to distinguish "clean" and "dirty" discomfort.

Then it will be low again. and willingness drops down. It's like a ratchet or something. If you stop trying to control anxiety. Sometimes it will be low. it will be high. it drives it in tighter. I promise you! Swear." 8. until it's not low and then it will be high. we will turn our focus to the willingness scale. It is not a reaction--not a feeling or a thought--it is a choice. and your experience says the same thing--if you want to know for sure where the anxiety scale will be. Unlike the anxiety scale. it simply doesn't work. and sometimes it will be high. the anxiety kind of locks into place. All in the name of getting it low. And when it is high it will be high until it isn't high anymore... though.. . very low and sooner or later when anxiety starts up the ratchet will lock in and you will have plenty of anxiety. You came in here with it set low--in fact coming in here at all may initially have been a reflection of its low setting. It's as if when anxiety is high. If you do this. which you can't move around at will. Homework a. and in both cases you will keep out of a useless and traumatic struggle that can only lead in one direction. and it just doesn't work. You've been trying to control Mr. your anxiety will be low . Instead of doing that. I'll tell you exactly what will happen and you can hold me to this as a solemn promise.[pause] or . really unwilling to have anxiety then anxiety is something to be anxious about. Meditation practice: clients are to practice the meditation exercise led in session daily and record this on their sleep diary and practice form Session 5 & 6. When anxiety is high and willingness is low. It's not that you weren't clever enough. I can guarantee you what will happen to anxiety. Review sleep diary and meditation 2. what we need to do in this therapy is shift our focus from the anxiety scale to the willingness scale. Sleep diary & practice form b. Just set willingness very. What we need to do is get it set high. then there is something you can do.But that is a terrible combination. Anxiety for a long time. it will be low. Introduce Self-as-context and Defusion Walk through the following exercises in order to facilitate defusion and self-ascontext: What are the numbers? 4/14/08 . I'm not teasing you. That's because if you are really. Hold me to it. It will be very predictable.. It's like that. And when it is low.. the willingness scale is something you can set anywhere.. if you set willingness high. the ratchet is in and anxiety can't go down. There just aren't good words for what it is like to have the willingness scale set high--these strange words are as close as I can get. You've had it set low. You turn the ratchet and no matter what you do with that tool. So. I can say one thing for sure. If you move the willingness scale up. Self as Context and Defusion 1. You know how a ratchet wrench works? When you have a ratchet set one way no matter how you turn the handle on the wrench it can only tighten the bolt. then anxiety is free to move.

touching the thought lightly with your mind. You are the one sitting in this chair. 4. Let your mind rest lightly on the breath. Tell the client that they are the observer sitting on the riverbank and calmly watching their thoughts float by. Introduce Values Hopefully at this point in treatment the client is becoming less involved in struggles with sleep-related thoughts and is having some improvements in sleep quality and/or medication use. Labeling the experience brings forth the observer. Notice that you are not your thoughts. and with emotions. Silently say to your “thinking. thinking”. When you notice that you are lost in thought. Values and Committed Action 1. though you may have believed you were for a moment. Consistent with this. 4/14/08 . your mind will begin to wander. such as planning. Then bring your attention back to your breath. Homework  Sleep diary & practice form  Meditation 5. thinking. body sensations. noticing the whole length of the breath … Eventually. watching it until it naturally fades. They can practice this on their own as a meditation exercise. or anything else that occurs in the moment. Leaves on a stream Walk through the Leaves on a stream exercise with the client and ask them to practice with you in session. Your breath reminds you of who you really are. Session review and check in (5 minutes) Session 7 & 8. Review sleep diary and meditation 2.” Labeling may also be used to label specific thoughts. milk. Some sleep researchers believe that daytime processes are just as important as those that occur at night. or obsessing.Chessboard Metaphor Milk. engaging in valued actions may be important for improving quality of life and refocusing attention away from sleep and on positive aspects of their life. simply label the process of thinking. worrying. breathing in and out. Labeling thoughts “Begin by bringing your awareness to the present moment. Meditation These exercises focus on building defusion and self-as-context. Pick one to guide the client through during the session and to assign as homework for the week. milk exercise 3.

your evaluation of him is absolutely distinct from you willingness to have him as a guest in your home. they're just more bums at the door. The client has been making commitments to increase his or her willingness throughout the treatment. why did he show up? But you did say on the sign. He's stinky and smelly and you think. other undesirable reactions follow along right behind: what one ACT therapist called "the bum's chums. This will aid in long-term outcome of the treatment because it helps direct the client in difficult situations. Additionally. Everyone's invited in the whole neighborhood--you even put up a sign at the supermarket. Are they welcome? Can you choose to welcome them in. what's the party going to be like?" The fantasy is that withholding willingness will promote peace of mind. God." 4/14/08 . 3. even though you don't like the fact they came? If not. the party's going on. The issue is the posture you take with regards to your own stuff. Your opinion of him. You don't have to like him. “Everyone's welcome. and now the commitment should be more focused on engaging in these valued activities. who lives behind the supermarket in the trash dumpster. Now you have to be at the front of the house. life's going on. fully. and here comes Joe-the-bum. You don't have to like the way he smells. Bum at the door "Imagine that you got a new house and you invited all the neighbors over to a party. is all the feelings and memories and thoughts that show up that you don't like. do that without liking that he's there? You can welcome him even though you don't think well of him. then you're going to have to be constantly making him do that. It's just not lifeenhancing. you only mean that he's welcome as long as he stays in the kitchen and doesn't mingle with the other guests. a housewarming.At this point in treatment the therapist should assist the client assessing his or her values. increasing the time involved valued activities will help maintain values driven behavior over behavior regulated by avoiding or escaping the obsession. Or if you say. Focus on committed actions After values have been clarified. or his life style. The Values Assessment Inventory is used to clarify the client’s values. most clients have noticed that when we try hard to stop one reaction from joining the party. It's not much like a party. and really. of course. What the metaphor is about. but you don't really mean it. Clarification of the client’s values assists in giving the client direction outside of the support of the therapist. OK. and you're off guarding the bum. So all the neighbors show up. You may be embarrassed about the way he's dipping into the punch or the finger sandwiches. and your whole party will be about that. in reality he's not welcome. Completing the values assessment inventory does this. See Appendix. Now you can decide that even though you said everyone was welcome. you're welcome. it is time to assist the client in shifting the focus to engaging in these behaviors. the party changes. guarding the door so he can't come back in. the party's going great. In fact. The following exercises will assist the client in engaging in valued activities over slipping back into an avoidance strategy. or his clothing.” Can you see that it's possible for you to welcome him. But as soon as you do that. The reality is the opposite. It's a lot of work. Meanwhile.

Without a goal and a commitment to values and goals. Use these for the following meditations. slow deep breaths. Now bring to mind an issue that you’ve been struggling with.g. notice what sensations you are experiencing in your body. As you hold this word in your mind. Think of an image that captures what you are experiencing – your boss frowning disapprovingly. and imagine that this light [their value] is filling them up … Think of someone you have difficulty with and imagine that this light [their value] is filling them up … Now imagine that every living person is filled up with this light and that you are giving this gift to all of them. or a fire with angry flames for example. you will have identified a few core values. a frightening monster. Notice your body contracting and any physical sensations that arise. sometimes there is a swamp there. On the out-breath.” 4/14/08 . Breathe into this pain wherever it is located in the body. It is that when we are going somewhere. and without it acceptance loses its direction. Only you can cast that string. contacting your value. On an in-breath. acquaintances. But notice also that there is a purpose to it. Acceptance is what happens when you are willing to go into that swamp. Then. Think of an image that captures what you are experiencing – a shooting star or a calm day on the beach or an image of a loved one smiling for example. you can always refer back to the string and see if you are headed in the direction you set for yourself.Moving Through a Swamp At this point in therapy. there is no need for willingness. “Imagine that this light is entering your body from the top of your head. It is not that we need to wallow in swamps. when you are up to your ass in goop. It is slowly filling you up with a glowing light. Meditation focused on Values and Committed Action By the end of this session. Ask them to identify a core value (e. love. and a sense of openness. Notice if there is lightness. warmth. notice how you are feeling in your body. bring to mind your struggle. 4. freedom) and imagine this exists as a ray of light. Imagine that this light is filling them … Now think of other people you know. permeating every cell with [their value] … Now picture someone close to you that you feel positively toward. and we have the choice either to change directions or to open up. It is as if you could cast a string across the swamp to reach a particular point on the other side. it is useful to explain to the client that the need for willingness emerges in the context of commitment. As you hold this issue in your mind. using the image you thought of or a word to represent it. Continue touching in on your pain on the in-breath and breathing out. Are you feeling tense? Try to contact a sense of contraction around the issue.” Tonglen meditation (ACT variation) “Close your eyes and take a moment to again bring to mind what you would consider a core value and find one word to describe it. It is as if there is a swamp in front of you. recall your value using the word or image that you chose. Now take several long. Metta meditation (ACT variation) Guide the client to bring their attention to the breath for a few moments. Breathe into a sense of openness and relaxation.

Homework  Sleep diary and practice form  Meditation led in session to be practiced at home (session 7)  Finish values assessment worksheet for session 8 (session 7) 6.Debrief: Does the pain and the value start to overlap? Is it difficult to separate one from the other? 5. Termination 4/14/08 .

Appendix A Sleep Diary I went to bed last night at: I got out of bed this morning at: Last night. I fell asleep in: I woke up during the night: (Record number of times) Last night I slept a total of: _____PM/AM _____PM/AM ____Minutes ____Times ____Hours ____ Minu Day 2 Yes/ _____PM/AM _____PM/AM ____Minutes ____Times ____Hours ____ Minu DATE____________ Day 3 DAY_____________ Yes/ _____PM/AM _____PM/AM ____Minutes ____Times ____Hours ____ Minu DATE____________ Day 4 DAY_____________ Yes/ _____PM/AM _____PM/AM ____Minutes ____Times ____Hours ____ Minu DATE____________ Day 5 DAY_____________ Yes/ _____PM/AM _____PM/AM ____Minutes ____Times ____Hours ____ Minu DATE____________ Day 6 DAY_____________ (Type & Dose) Yes/ DATE____________ DAY_____________ Practi (Record number of hours) Day 1 DAY_____________ Medications: Yes/ _____PM/AM _____PM/AM ____Minutes ____Times ____Hours ____ Minu DATE____________ 4/14/08 .

Day 7 DAY_____________ Yes/ _____PM/AM _____PM/AM ____Minutes ____Times ____Hours ____ Minu DATE____________ 4/14/08 .

Rate how successfully you have live this value during the past month on a scale of 1 (very successfully) to 10 (not at all successfully).Appendix B Values Assessment Rating Form Read and then rate each of the values narratives generated by you and your therapist. 2 the next highest. with 1 being the highest rank. and so on. on a scale of 1 (high importance) to 10 (low importance). Rate how important this value is to you. Finally rank these value narratives in order of the importance you place on working on them right now. Couples/Intimate Relationships Family Relations Social Relations Employment Education and Training Recreation Spirituality Citizenship 4/14/08 Rank Valued Direction Narrative Success Domain Importance Rating or Rank .