acceptance and commitment therapy+protocol+for+developmentally+disabled+psychotic+individuals

7/31/2019 Acceptance and Commitment Therapy+Protocol+for+Developmentally+Disabled+Psychotic+Individuals

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Acceptance and Commitment Therapy Protocol for Developmentally DisabledPsychotic Individuals

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


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ACT Therapy for Psychosis/Mental Retardation

This Protocol:

This protocol does not contain an extensive theoretical rationale for the procedures usedin 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 Languageand Cognition (Hayes, Barnes-Holmes, & Roche, 2001).

Psychosis and developmental disability: the connection

Despite the increasing variety of available anti-psychotic medications, many psychoticindividuals 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 distressrelated 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 ofconversation, and blunt affect.

The co-morbidity of psychosis in individuals with developmental disabilities may

exacerbate the financial strain, emotional turmoil, and difficulties in adaptive functioningthat 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 ofpsychopathology. 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. Traditionaltreatments 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 asa 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, andvalues in order to increase acceptance of unavoidable private events such as urges to use


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substances and the presence of odd cognitions. The ACT stance rests on noticingaversive emotions and/or bodily states rather than attempting to control them.

This ACT protocol situates willingness as the vehicle by which individuals learn thatacceptance of aversive private emotion or bodily states is a process, not an outcome. The

individual learns that through awareness, vulnerability, flexibility, and willingness onecan begin to let go of old control agendas (e.g., increased "buying into" the veracity ofdelusional 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 inembracing 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 madeattempts 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 oddcognitions without active attempts to control or modify them may increase client

outcomes.

Some basic hypotheses:

1) Delusions are often avoidance maintained and aprocess orform of emotionalavoidance. 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 inthis 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 moredifficulties 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 thatthey 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 tocontrol 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 avoidancestrategies which are less tolerant to direct intervention.

3) If delusions themselves are verbal avoidance strategies, it is not so much thedelusional process that needs to be accepted but rather the feelings of failure,


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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 decreasebelievability of symptoms, decrease distress related to positive and negative symptoms,increase adaptive functioning, and increase medication compliance.


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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 andDirty Glass metaphors

Session One Check in

Noticing and naming thoughts (distancing exercise) Thoughts Riverexercise

Discuss continuum between psychotic symptoms and Tug of Warmetaphor

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 Sell Me A Reason exercise

Explore past coping efforts/workability List and discuss costs of

using and/or "buying into"

odd cognitionsDiscuss successful working Tour Guide metaphor

Session Two Check in.

Noticing thoughts/defusion Thoughts Riverexercise

Discuss notion of link between thoughts and them

"causing" distress. Reasons are NOT CAUSES Museum of Reasons

metaphor.

Discuss notion of needing to be "right" Discuss dusty, well

hovered over artifacts.

Down in the Cellar

metaphor

Control as a problem/Letting go of the struggle Invitation to the Room

metaphorNormalize experiences urges/positive and negative symptoms

Have the client list symptoms in detail, how distressing Wearing Symptoms

they are, and how they attempt to control them List symptoms on

differing cards.

Willingness/Acceptance Ask client to pin them on,

or in effect, to wear them

on themselves

Session Three Check in.

Noticing thoughts/defusion/ Introduce believability Thoughts Pie/ % True"

Distancing with defusion as a target Sticky clumps of yarn

metaphorDiscuss issues of function of odd cognitions/urges to use Thoughts Parade

metaphor

rather than focusing on form or frequency Hierarchical noticing

Language around thoughtsbarriers to acceptance "I'm having the thought

that"

Getting off of our

buts/and

Goals and Action Commitment and goals

Shield of Armormetaphor


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Session Four Check in.


Values as a context to place action/goals Values Highway exercise

Discuss goals, action, and barriers

Past control attempts have hindered successful working Stones to Make aBridge

Commitment to self Self in Chairexercise

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 Thoughts Pie/ %"true"

exercise

Willingness/exposure 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

Description and evaluation of behavior and self Distinguish betweendescriptions and

judgments of self.

Court Reporter, Lawyer,

and Judge metaphor

Session Six Check in.


Box of Marbles metaphor

Hallway with Rooms

Experience and self as context Sitting on the Beach

Acceptance Accept all, even if some

parts are not as well liked

I am. (period) exercise

Session Seven Check in.

Interpersonal relationships/values Matter O Meter

Flexibility Social Dance metaphor

One Note on the Piano

Thoughts as bullies

Sound out/Sing/Silly voice

Control as a problem/letting go/coping with urges Rumpled Old Shoe

Bathed in your own experience Lighthouse metaphor

Acceptance 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


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5) successful working in

adaptive domains

6) relapse prevention

Saying Goodbye History is additive so now

this is part of their history

Tying it all together--

SpiralStaircase metaphor


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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 Glassmetaphor**ACT handbook

2. Assessment of adaptive functioning (self report). Address communication, dailyliving skills, personal hygiene, socialization, motor skills, and psychotropicmedication 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 assessmentare:

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 classesof 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 interferingwith 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 assessmentare:

Detail behaviors which function as avoidance moves (e.g., psychoticsymptoms, 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., anyinterpersonal 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


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Session One

Session Targets:

A) Noticing and naming thoughtsB) Letting go of the struggleC)

Function of reasonsD) 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 theclient 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 thatthey 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 thediffering 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 thethoughts 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 theRiver 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." Useexamples 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 abovethoughts 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 thatreason-giving is like a hall of mirrors that continues to reflect into infinity. Point


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out that there is no true peace found through hunting for the "Great and GoldenReason Why."

Attempt to undermine the client's confidence in reasons. This is in service ofbeginning 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 thatshould 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, physicalhealth, and employment.

If the client has insight into the function of positive and/or negative symptoms ofpsychosis serving as avoidance mechanisms, introduce the idea of how "buyinginto" 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 opportunitiesfor 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 psychologycontent. Unworkable strategies ultimately are that--unworkable. Successfulworking 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 atchange. 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 ACTchallenges 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 experiencetell 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.


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Session Two

Session Targets:

A) Noticing thoughts/defusionB)

Reasons are not causes/right & wrongC) Control as a problem

D) Thoughts and their link to distressE) 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. Askthe 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 tothem 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 forthe 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 throughaction, judgments, or active attempts to control the thought. Tell the client that

the "river of thoughts" is something that you will be revisiting frequently duringthis 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" ofdistress. Remind the client that we have already discussed the trap that reasonscan 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 museumthat is well tended by them, well hovered over. The pieces on display representstories related to "reasons why." There is a special shrine of "favored" pieces


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represented by Righteous Indignation. Ask the client which pieces are so old theyare 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 thatthese historical artifacts are governing the way the client is currently living their

life. Discuss ways the individual is actively attempting to control or avoid currentexperience by focusing on past "wrongs" and "reasons." Link current struggleswith 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 bodilysensations. In effect, attempts to control experience may paradoxically serve to

increase

The form or frequency of the experience. Control as a problem can beexperientially 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 clientimagine 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 moredifficult 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 isstanding 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 willingto 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, relatingfeelings 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 isdoing 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, includinghow they are all interacting with each other. Normalize and validate distress

related symptoms.

5. Physicalizing Exercise/ Wearing Thoughts and Symptoms.


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Now that the client is "sitting in the room" with some of their thoughts and hasdescribed 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 overit"). 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 theirpocket 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 increasingwillingness.


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Session Three

Session Targets:

A) Defusion and believabilityB) Distancing with defusion as a targetC)

Language around thoughtsD) 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 theprevious 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. Discussdefusion 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 itinterferes 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 theirproblem 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 thestory rather than making actual progress on the underlying problem or distress.

Introduce the Thoughts Pie, % True exercise. Have the client draw a pie chartand 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. Wewant 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 weare 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 themby 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 thethought and behavior changes.

After the pie chart is filled in, ask the client to tell you which ones are "true." Areall 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."


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Discuss with client "truth" in terms of what works as a process, rather than a focuson 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 thoughtautomatically 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 theThoughts 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 onthem 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 ifparticular 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. Amajor target is an assault on the client's use of the word "but." Butis commonlyused to specify exceptions, carrying with it an implicit statement about the

organization of psychological events. For example, the client may "see" in theirparade 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 usinto 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 theproducts 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 thatthe 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 isto 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


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processes, and more global barriers to functioning. If the client cannot identifymeaningful 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 writetheir name on the shield and to write on it what type of shield it is, e.g., have themimagine 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 theclient 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.


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Session Four

Session Targets:

A) Noticing thoughts/defusionB)

ValuesC) Action and Barriers

D) Commitment to self1. 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 ACTperspective, 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. Theonly 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 thehighway 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. Ifthe 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 probefurther 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 perceivestheir life.

Discuss the importance of seeing life as a process, not an outcome. It is about ameta-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 toworkin 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 privateevents can be hurtful, much less going through the motion of chiseling them into


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rock. Have the client imagine that at the end of the day there are a number ofrocks 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 rivercutting 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 thebridge over the river. Have the client imagine an attempt at a warm, positivefeeling 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, aspieces 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 tocommitment. 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 beingpartly willing. Self-acceptance can allow commitment to be kept.

Have the client orient to the path in front of them. Commitment involves elicitingand sustaining behavior change. Discuss with the client that they will be temptedto "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 afeeling 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 yourbehavior. 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 thechair and close their eyes, imagining that the "core of themselves" is sitting acrossfrom 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 acontext 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 andto continue forward anyway. Discuss with the client the utility ofemphasizing 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.


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Ask the client if they feel they have clarity around values and how they canfunction 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 maybe 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 areuncomfortable about speaking out about values in order to demonstrateexperientially the process of having discomfort andtelling it anyway. This is like

life in that we can be challenged andmove forward in valued life directions.


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Session Five

Session Targets:

A) Defusion/believabilityB) WillingnessC)

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 SessionThree. 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, andothers 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 noticethe 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 ThoughtsPie during this session. We are doing to talk about the thoughts in terms ofwillingness. 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--throughcolor, 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 clientimagine 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/aversivebodily sensations and/or urges and distancing from evaluations/judgments aboutthem, 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


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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 mayhave about themselves. Discuss this in terms of a change in stance we are askingthem 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 actualusing 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 ofengaging 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), andc) 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 mindto be bad equals me).

Once the client understands that the target is the relationship between the thoughtand the experience of it, not the thought per se, or the experience per se, we havelaid 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 comeprepared next session to discuss self and how we "language" about self.


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Session Six

Session Targets:

A) Noticing thoughts/defusionB) Self as context versus self as contentC)

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 usthat 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 theclient, 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 ACTmodel assumes that it is this particular type of statement which creates severeproblems 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 self-

deception. An ACT stance is one of helping clients to distinguish themselvesfrom 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, individualsmay work to defend their conceptualized self even if the contentis loathsome to

them because theprocess 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 privateexperience. 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


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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 contextpresented 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 standand 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 woodenhandrail. 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 isnever 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 feelthe 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 tonotice 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 comfortedby this type of "constant self."

Another way to talk about this constant self is to have the client imagine Sittingon 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 tidecomes 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 theoverarching, meta context in which all "rooms" of content exist.

It is important to highlight that self as context, while comforting and steady, is notsimply the product of all the "positive" parts of oneself. Demonstrate the balanceand completeness of self as context through the Box of Marbles metaphor. Have


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the client imagine that thoughts/feelings/experiences/memories (etc) that theyhave 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., theblack 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" itin session for you, by imagining the shape and color of it. Tell them that the bagor 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 imaginea 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 thebox/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 thisexercise 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. Describehow willingness to experience self as context and to distance oneself from self ascontent 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 thingsevaluated as goodandbadin 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 apiece 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 pieceof 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.


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Session Seven

Session Targets:

A) Interpersonal relationships and valuesB) FlexibilityC)

Control as a problem/Letting go/Coping with urgesD) 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 torecall what values were related to relationships with other people. Most

individuals will have expressed within their value set some version of wanting toconnect 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 agauge 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, askingfor 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 therelationship matters and how they can go about expanding the relationship.

Situate the entire conversation within the scope of a valued life direction whichincludes 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 hownot 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 thatsometimes 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 describethe 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 thanlooking 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 andto 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.


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Another way to express flexibility to the client is through the One Note on thePiano 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 meetingother people, along with the first physical impression we receive, we are also

treated to listening to their own "personal musical score." Ask the client whattype 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 beingopen, 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 oldtroubling 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., havethem 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 speakingfunctions 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 seare 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 adiffering 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 aremighty 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 sameresponse 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 ofverbal languaging about it. However, the true nature of acceptance is an elusive


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blend of awareness, balance, and willingness. Psychologically, it connotes anactive 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 theoutside 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.


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Session Eight

Session Targets:

A) Wrap up on ACT targetsB) 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 toexpress 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 theirimpact on you.

Do a global overview of the major ACT targets. Focus on 1) noticing anddistancing oneself from thoughts, 2) noticing and following values, 3) actionbased 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. Althoughthe 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 onehand 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 stayfocused 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 lineexactly, 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 walktheir path of life.

Have the client draw hand railings up the sides of their staircase. Have them writeon the handrails the values they have unearthed through the ACT therapy. Askthe 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 andto provide boundaries. Have the client add goalshanging 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 landmarksalong the way.


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Have the client turn the paper sideways. Now the "spiral staircase" lookssuspiciously 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 allfacing struggles in content areas which feel like "big steps." We may even feellike 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 entrappedor 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 thehand 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 towalk 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 havelearned.

acceptance and commitment therapy+protocol+for+developmentally+disabled+psychotic+individuals

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