When suffering knocks at your door and you say there is no seat for him, he tells you not to worry because he has brought his own stool.
—Chinua Achebe
A great deal of struggle and suffering arises from denial of the inevitability of human pain. When we feel fear, anxiety, sadness, hopelessness, or other emotions that cause distress or discomfort, or when we think of ourselves as less than worthy, we often engage in efforts to undo those experiences. With or without awareness of another option, we pick up the experiential control agenda and go to work. A battle with our internal experiences begins. Unfortunately, because we are largely the products of our history and cannot simply eliminate it or the content it contains, the agenda of experiential control is largely ineffective, and in many cases it backfires, trapping us in an unsuccessful struggle with ourselves. In addition, experiential avoidance often creates a self-amplifying loop that leads to additional suffering. The result can be years of life consumed by fruitless efforts and potentially self-destructive behavior directed toward unworkable ends.
This tendency toward experiential avoidance is a basic part of being human; it is born out of language and amplified by culture. We all try to control painful experience to some degree or another, at times working feverishly to avoid painful events. However, because pain is also a basic part of the human condition, we don’t have long-lasting or viable ways to escape the experiences that are elicited when we encounter loss, unmet desires, and other similar conditions. Although control methods sometimes work in the short run, they tend to have the paradoxical effect of increasing suffering in the long run. Amplification of suffering can occur both through the basic properties of language (for example, trying not to think about an unpleasant memory can evoke that memory) and through the loss and pain that can result from living outside of our closely held values (for example, a person with social anxiety who wants connection with others may avoid people out of fear of experiencing anxiety and shame).
ACT specifically targets letting go of misapplied control, or control that is aimed at reducing or getting rid of experiences that cannot be gotten rid of in a healthy way. As an antidote to increasing suffering by engaging in ineffective control efforts, ACT offers an alternative that helps clients contact unwanted experiences, and helps them do so without excessive or rigid efforts to make the experience be other than what it is. This alternative is willingness.
“Willingness” can be defined as being open to the entirety of one’s experience while also actively and intentionally choosing to move in valued life directions. Developing willingness occurs through a process of contacting the present moment as it is, with whatever internal experience is present, while simultaneously taking action that is guided by values-based intentions. It is foundational to the first of the three pillars of flexibility: openness. Willingness to experience is the seed of openness. The opposite of willingness, excessive and misapplied control of internal experience, also points to what we’re exploring when working with clients on this process: when people are unwilling, they may make choices based on a desire to avoid internal experiences, rather than on their personal values.
Willingness is an action and has an all-or-none quality to it. It’s like a leap. For an action to be a leap, we need to momentarily be completely in the air, with no part touching the ground, allowing gravity to do its work. Leaping has a different quality than stepping, wherein each movement is controlled. A step can be a large step, but it’s still a step, and a step can only take us so far. We can step from a chair, but not from a roof. Conversely, leaps can be small, but they have no upper limit. The motion involved in a leap from a chair is identical to the motion involved in a leap from a roof. We are either in the air or not—just as we are either willing or not.
Although having tolerance can bring us a step closer to being willing, tolerance implies that negative experience is to be withstood until something better comes along. We might “white-knuckle” our way through strong unwanted emotion as if to conquer the experience. This still has the quality of taking a step. Willingness, on the other hand, has qualities of openness, allowing, and being present with whatever is there to be felt, sensed, or observed. Willingness is experienced as an ongoing process, not as waiting for something to change for the better if we’re tolerant enough. Willingness to experience, then, is a stance that can be taken again and again; it is a lifelong series of choices related to how we will bear our experience.
It’s also worth noting that people can seek to avoid or escape positive emotions. For example, people may have learned to not allow themselves to relax because doing so has previously been followed by painful experiences, or they may not allow themselves to experience or express joy because this has previously been followed by attention from others that leads them to feel uncomfortable. Thus, avoiding or controlling positive emotions and their expression can also create problems in terms of increasing suffering and harming interpersonal relationships (e.g., Gable, Reis, Impett, & Asher, 2004). In addition, avoiding positive emotions may interfere with maintaining committed action, since it may lead people to miss out on other sources of reinforcement that may be present when they live in a way that aligns with their values.
Clients often confuse willingness with a feeling or way of thinking. However, people need not feel willing or think in a particular way in order to be willing. Willingness is also not about wanting. People don’t have to want to feel or think something to be willing to do so. The question is whether they would be willing to experience these feelings and thoughts fully and without defense if that meant new possibilities would be created in their life.
Willingness is an inherently active process and arises from remaining aware of and open to the thoughts, feelings, and sensations that arise when taking action in the service of one’s values. This includes all forms of committed action. It may entail making a telephone call to an estranged friend, having a conversation with a loved one when fearing or not wanting to do so, laying down one’s defenses despite wanting to argue for something, or saying “I love you” even though it feels scary.
For the purposes of this book, we use the terms “acceptance” and “willingness” interchangeably. Unfortunately, the term “acceptance,” in some contexts, can carry a lot of cultural baggage, which may make it less useful with some clients, particularly those who have been on the receiving end of lectures about how they have to accept something. Acceptance and willingness are not about loss, resignation, or stoicism. Yet for some people, “acceptance” sounds like resignation, and indeed, sometimes our culture defines it that way. Likewise, loss and resignation in the presence of pain can be viewed as giving up or submitting to it, and stoicism may be viewed as a kind of indifference to emotion. None of these is the kind of acceptance we’re talking about in ACT (Hayes et al., 2012). If a client reacts to the term “acceptance” in any of these ways, it is better to use the term “willingness.” In fact, it’s useful for therapists to keep an eye out for negative connotations clients may associate with both of these terms, or others. We want to use terms with connotations that are predominantly life affirming, empowering, and vitalizing and that support openness, awareness, and engagement—the three pillars of flexibility.
A fuller understanding of what ACT means by “acceptance” can be illuminated by the historical origins of the word. “Acceptance” can be traced back to a Latin word meaning “to take or receive what is offered.” This implies an action of embracing, holding, or taking what life offers—and doing so willingly. Acceptance is ultimately a choice to embrace what is and what life offers, saying yes to life and its variability in experience.
Before we turn our focus to clients, we want to highlight that willingness also applies to therapists. It’s common for therapists to find the process of learning an experiential therapy like ACT anxiety provoking. At times, doing so may increase your level of self-doubt or self-criticism. This is natural when learning something new, and even more so with a therapy that emphasizes experiential and nonlinear learning, as is the case with ACT. We hope you’ll be open to engaging the experiential learning process in this book while also making room for and learning from whatever reactions you have as you do so.
Willingness is foundational to ACT and is one of its key functional goals. Willingness, or acceptance, can’t just be described to clients with the hope that the descriptions will provide benefit (i.e., the client will be more accepting or willing based on the description); these are skills to be learned, not concepts to be understood. In ACT, therapists attempt to build the behavior of acceptance by engaging clients in specific activities structured to create the possibility of choosing to experience difficult thoughts, emotions, sensations, and so on.
Rigid and misapplied attempts to control and manage unpleasant, unwanted, and difficult internal experiences can cost people in at least two ways. One is that the things people do in attempts to reduce or remove their painful emotions, thoughts, sensations, and memories often fail and, paradoxically, may produce even more distress. The pain and struggle caused by efforts to not have pain as it is, sometimes referred to as “suffering,” is added to the pain that is the natural and automatic result of living life. In fact, some research has shown that attempts to suppress troubling thoughts or emotions tend to result in rebound effects, wherein the emotion or thought becomes even more prominent (Hayes et al., 1996; Abramowitz, Tolin, & Street, 2001). Efforts to not think about a bad memory often tend to elicit that same memory (e.g., in PTSD; Shipherd & Beck, 2005). Similarly, depressed people who stay in bed all day to escape from the perceived meaninglessness of their life only further confirm their fears about the meaninglessness of their life. And panic, at least in part, is often the result of a struggle to not have panic. Many more examples of the paradoxical effects of experiential avoidance are given in other ACT texts (Eifert & Forsyth, 2005; Hayes et al., 2012) and reviews of the literature (Abramowitz et al., 2001).
Another consideration is that living life in pursuit of feeling good generally isn’t living in the service of deeply held values. Doing what’s important or what matters is sometimes painful or can at least create a sense of vulnerability—precisely because caring reveals where we can be, and have been, hurt. This connection between pain and values is part of why the costs of experiential avoidance are so high. It can lead people to turn away from valued directions, relationships, or activities in the service of modulating, controlling, or avoiding particular experiences. To return to an earlier example, a person with social anxiety may have very few friends because of a desire to avoid shame, yet that very shame may be an indication of how important others are to that person. Similarly, people who engage in chronic, persistent experiential avoidance may never develop a sense of what they desire in life because they’re so caught up in not feeling. In the end, a life lived in pursuit of feeling good may not feel very good.
Willingness is closely linked to cognitive defusion (see chapter 3), and an extended discussion of this link seems warranted here. Because we humans tend to become fused with language in a literal way, we often fail to distinguish between the world as we verbally conceive of it and the world that we directly experience. The world simply seems to occur as we perceive it. We don’t always realize that this is actually a result of a blending of direct experience and thought. We are fused—entangled—with our minds. Under these circumstances, the verbal content of the mind dominates over behavior, and the direct contingencies of experience are lost. For example, with fusion, a client who says, “I can’t stand this feeling another moment,” holds the ideas that he will fall apart, cease to exist, or be damaged if the experience of that feeling continues. However, with defusion or freedom from the literality that the mind presents, that same client can attend to his direct experience. He can and will stand the feeling for another moment, and will also experience that he doesn’t cease to exist. Furthermore, with attention to the ongoing flow of his present-moment experience, he will learn that this feeling will pass and another will come along, time and again.
One of the main issues with fusion, as it pertains to this chapter, is getting fused with culturally supported messages that negative thoughts and emotions are disordered and problematic and should be decreased or removed, as well as messages that wholeness and well-being are largely defined by feeling good and that we should do what it takes to feel that way. bell hooks captured this well: “One of the mighty illusions that is constructed in the dailiness of life in our culture is that all pain is a negation of worthiness, that the real chosen people, the real worthy people, are the people that are most free from pain” (1992, p. 52). When people entirely buy into these cultural messages, they begin to engage in behaviors consistent with the messages—behaviors that are designed to reduce or eliminate negative thoughts and emotions in the service of attaining well-being. And when people view negative thoughts, emotions, and sensations as disordered and problems to be solved, they tend to engage in a logical problem-solving process: figure how to get rid of it and then get rid of it. They plan, try to understand, and try to find solutions; they try to resolve, answer, unravel, decipher, and explain and may expend a lot of time on a host of behaviors designed to allow them to feel, think, and sense something other than the undesired experience. Years or decades can be spent in this very effort.
These efforts seem to make sense; they seem logical. We humans have learned that problems are made to be solved, and indeed, in the world outside the skin, problem solving is an excellent strategy: If you don’t like the way the room is arranged, rearrange it. If you don’t like dirty dishes in the sink, wash them and put them away. If you don’t like long hair, get a haircut. Figure out how to fix the problem and then fix it. But when this strategy is applied to internal experiences—the world inside the skin—the very efforts to fix them may actually sustain and even increase the experiences we’re trying to eliminate. Nevertheless, we still engage the strategy: If you don’t want or like anxiety, figure out how to get rid of it, and then get rid of it. If you don’t like sadness, disappointment, thoughts, memories, or sensations, figure out how to get rid of them, and then get rid of them. But because the world inside the skin doesn’t work in the same way as the external world, trying to reduce and eliminate internal experiences may actually cause these experiences to linger and grow. A classic example is that not wanting anxiety is itself something about which to be anxious. So the “problem” grows. And because our logical, problem-solving minds are so heavily involved, we conclude that what’s required is more strategies aimed at fixing the problem; we need more control.
A major focus of acceptance, then, is to undermine the strategy of excessive internal control by examining the workability of this strategy. The focus is on clients’ experience with this strategy, not logic, as logic is part of the self-perpetuating system that tells clients they should be able to control their emotions, thoughts, and sensations.
The clearest signal to engage willingness processes in session is experiential avoidance. When clients make efforts to control or escape difficult material that’s touched upon in session, willingness work can be helpful. That said, the clinician shouldn’t just jump into a willingness exercise haphazardly; it’s important to have the session flow, working in willingness processes and exercises as appropriate to meet the needs of the client.
Recognizing experiential avoidance can be hard at times and easy at others. There are a number of ways that clients may demonstrate that they’re trying to control internal events. They may change the topic, become superficial, make jokes, deny that issues are present, look away, get angry, get very wordy, or use words that seem incongruent with their affect. If these behaviors occur when difficult topics or experiences come up, they are probably avoidance behaviors. Others signs of in-session avoidance include physical postures indicative of hiding, fighting, or fleeing, such as freezing, clenching the jaw or fists, fidgeting, or looking away or down. Yet other signals include inaction, excessive planning and rumination, argumentativeness, lack of motivation, or passivity on the part of the client—a sense that the client is trying to hand over responsibility to the therapist. Avoidance may also be an issue if the client has a hard time savoring positive experiences without a fear of them ending. These are just some of the many manifestations of avoidance behavior. Whatever the behavior, the key to recognizing what should trigger working with willingness is the function of the behavior: Does it function to avoid or escape unwanted internal experience in a way that is inflexible?
The clinician’s reactions can also provide an effective guide to whether experiential avoidance is present in session. Client avoidance may be an issue if the therapist feels boredom or feels frustrated and has the urge to push the client to do something. Another possible signal is if the therapist has a sense of wanting to argue with the client or feels a need to convince the client. Sometimes the therapist might detect avoidance only after the fact, suddenly thinking, How did we get on this topic? only to realize that the client had previously deflected from a more difficult topic. Clinicians engage in emotional avoidance in session too. They sometimes avoid talking about potentially sensitive topics or fear that they may scare or harm a client. It’s important to pay attention to such experiences. They too should trigger working with willingness, not only for the client, but for the clinician as well.
The process of developing acceptance usually involves two major focal points: creating an initial openness to willingness by undermining experiential control as a dominant method of relating to oneself and the world; and actively developing and choosing willingness through structured practice and committed action. Both of these steps are intended to foster psychological flexibility: the ability to contact the present moment more fully as a conscious human being and then to change or persist in behavior in order to serve valued ends. This conscious sensitivity to context makes room for choice. Creating an initial opening for willingness is often where ACT starts, and in many cases, these initial steps are integrated into the assessment process.
Experiential avoidance and control efforts can be so well practiced that they occur virtually without awareness. For many people, managing and controlling their internal experience is not viewed as a choice; rather, they see it as just “the way it is.” The idea that they might choose to take a stance of willingness and feel anxiety, sit with pain, rest in sadness, embrace fear, or relax into uncertainty is so unusual and novel that some may feel it’s a bit like suggesting they could live without breathing. Particularly for clients with pervasive and chronic histories of experiential avoidance, substantial work is needed to clear a space wherein willingness, acceptance, and compassion can grow. This process can be broken down into three steps:
The outcomes of the process of undermining the control agenda are a loosened attachment to the eventual success of the experiential control agenda, decreased confidence in that success, and freeing up some space for clients to practice willingness and acceptance in such a way that these new strategies are less likely to get pulled back into the old system. The term confronting the system, which is sometimes used to describe this process, is helpful for orienting therapists to the idea that this isn’t about confronting the client, but about confronting the social, verbal, and cultural system of experiential control in which the client is stuck. The confrontation is not between client and therapist; rather, it’s a confrontation between the client’s lived experience and the mind’s proposed solutions to problems that are the result of social and cultural conditioning.
Let’s take a detailed look at the stepwise process of creating an opening for willingness.
Undermining the control agenda begins with developing an understanding of what clients are trying to control with respect to their internal experience. This is usually reflected in the presenting problem (e.g., “I’m too anxious” or “I don’t want to be sad anymore”). The therapist might ask, “What brings you to therapy?” Almost always, clients report a struggle with emotions (e.g., pain, anxiety, fear, a sense of emptiness), memories (e.g., trauma, family experiences), or thoughts such as self-evaluations (e.g., self-doubt, a sense of worthlessness). Once the therapist has a good idea of what the client is trying to control, it’s possible to move on to explicitly drawing out the strategies the client has used in an effort to solve the presenting problem. To be clear, in using the term “strategy,” we aren’t necessarily implying that clients are conscious of or intentionally choosing a particular behavior; we are simply highlighting the fact that their behavior has a purpose. The term “strategy” also draws attention to the function of the behavior. This is important because the target of change is the function of the behavior, not its form. For example, with an anxious client, the therapist can talk about things the client does when she feels anxious (e.g., “I stay home,” “I get quiet,” or “I drink alcohol.”). Similarly, with a depressed client, the therapist can identify what that person has done to try to get rid of or manage the depression (e.g., “I lie in bed” or “I try to build my self-esteem.”). All methods of solving the problem should be explored, including seemingly healthy ones, such as counseling, getting help from others, and psychopharmacology.
Clients often aren’t aware of the variety and extent of the ways in which they attempt to control their private experience, and they aren’t always able to describe or identify the purpose of their behavior. Thus, part of the therapist’s job is to identify the function of the client’s attempts at solutions and to suggest to the client that these behaviors are about experiential avoidance. For example, a client with depression may not immediately see how oversleeping or overeating is typically intended to help him avoid or modulate a mood state or to decrease unpleasant rumination. As clients become better at tracking the purpose of their behavior, this can help them develop more present-moment awareness and better observe their behavior.
All of that said, in many cases clients are aware of the function of their behavior and fully cognizant of what they’re doing when exercising internal control. However, they can still be invested in the strategy, believing that thus far they’ve failed to implement it correctly, that they aren’t strong willed enough, or that some other flaw is interfering with their capacity to fully control and manage their experience. Therefore, they often continue to engage in these strategies, hoping that they will eventually work.
Concurrent with drawing out the client’s system of control efforts, the therapist’s job is to examine the workability of the client’s behaviors, particularly over the long term. The basic question asked here is whether the various control-oriented solutions to the client’s problems turned out as planned. There are two areas of workability to explore: actual or long-term outcomes in terms of suffering, and personal costs in relation to values.
The reason to explore both of these aspects—long-term outcomes and personal costs—is because the two are linked in the experiential control agenda (Hayes et al., 2012). The most obvious promise of this agenda is that through deliberate, conscious control, we can have more, better, or different emotions, self-evaluations, thoughts, sensations, or images. The first aspect examines whether this promised outcome has been achieved. However, we don’t merely want to feel good; we also want to live well, enjoying full, rich, meaningful lives as defined by our particular dreams and life aspirations (i.e., values). The most enticing promise of the experiential control agenda is that it can deliver that kind of life. Our culture tells us that once we are able to feel more happy, joyful, and energetic, and less anxious, depressed, sad, regretful, tired, and angry—or once we have different self-evaluations and thoughts—we will be able to live our dreams, have better relationships, lead a more vital life, live our values, find more meaningful work, and so on. Unfortunately, the reality is often the opposite; indeed, as alluded to earlier, people’s lives can become consumed with efforts to achieve the first goal of experiential control (decreased suffering), apparently in service of the second goal (living a valued life), but actually at the cost of the latter.
We have a few important points regarding the therapist’s stance during this process of examining the workability of the client’s behavior. First, the therapist should take the position that whatever the client has done is understandable and reasonable—which indeed it is, given the client’s history (Hayes et al., 2012). This stance also involves a genuine and compassionate approach, from a position of equality, that recognizes the very human desire to be happy and live well. If the therapist approaches workability from a one-up or overly confrontational position, this may come across as shaming or blaming. This is why we refer to confronting the system. A person caught in the system is not to be blamed; rather, the therapeutic approach is to work together to explore the system that entangles humans lives to such a great extent that we suffer tremendously. It’s also important to focus entirely on the issue of workability, not whether the therapist or client is “right.” This work isn’t about proving to the client that the therapist has a better way. That would be fundamentally antithetical to the basic ACT stance. Rather, the therapist’s job is to help clients start applying the criterion of workability, given their life goals and aspirations.
A word about pitfalls: For therapists doing this work, it can be hard not to get caught up in the content of what clients are saying. However, when focusing on undermining control, the therapist’s job is to consistently return to the issue of whether these strategies have worked in the client’s life.
Because clients’ verbal formulations are well practiced and even at times cherished, clients may feel threatened and begin to defend their actions or give reasons for what they’ve done. This is a normal and understandable reaction to this process. There are several ways to respond to this kind of reaction. One is to continue to focus on what clients’ experience has shown, in contrast to what their mind promises should happen. Another way to respond is to ask clients, in a nonjudgmental and nondefensive way, to step back for a moment and consider defending the rightness of their views as a strategy, and particularly how well this strategy has worked in their life. For example, the therapist might say, “Let’s take a look at what’s happening. In this moment, it seems that you’re defending this approach. Has defending it worked in the long run? I’m not sure whether the approach is right or wrong, but has taking this position worked to get you where you want to be in your life?” When saying something like this, it’s important not to speak from a place of trying to be right and make the client wrong, but from an honest examination of whether this control strategy has worked for the client.
Another common pitfall arises when clients say that a particular strategy has worked. In this context, clients are usually referring to the strategy’s short-term effects, so the therapist’s job is to help the client examine its longer-term workability. If the client also defends long-term workability, the therapist can gently inquire about the need for therapy, saying something like, “Then help me better understand why you’re here. Why do you continue to seek therapy?” (For more about elucidating the client’s pattern of behavior and examining workability, see Hayes et al., 2012, pp. 167–176.)
Exploring past and current attempts at experiential control is likely to show that these solutions haven’t worked well or have come at considerable personal cost. To help clients move from recognizing the downsides of control to beginning to engage in willingness, ACT therapists foster a sense of creative hopelessness (Hayes et al., 2012, pp. 189–197) and may use a number of metaphors and exercises to explore this experience with clients. It’s important that the clinician thoroughly understand the term “creative hopelessness” before embarking on this work. It doesn’t refer to making clients feel a sense of hopelessness in general; it’s about helping clients see the hopelessness of an agenda of internal control. The function of creative hopelessness work is to make room for something other than control: helping clients open to the possibility of willingness.
Sometimes people who are learning ACT mistakenly believe that “creative hopelessness” refers to a feeling and therefore think they need to make clients feel hopeless. However, creative hopelessness is actually a profoundly validating stance. Therapeutically, it refers to the process of validating clients’ experience of the futility of the struggle in which they have been caught, and then helping them begin to open up to the entirely new possibilities that come from this self-validation. Clients know that what they’ve been doing hasn’t been working. The possibility ACT therapists add to the mix is that this experience may be valid: perhaps it can’t work.
Once the therapist and client have explored the workability of many different behaviors and both have a sense of the extensiveness of the problem and the client’s attempts to solve it, the therapist may attempt to develop creative hopelessness in that moment, generally using a metaphor to capture the experience that has been discussed. The therapist can use any of a number of stories and metaphors about situations in which a great deal of effort is put forward with little payoff or where the effort actually creates more problems. The key is to find a metaphor that’s apt for the specific client and resonates with her experience, taking into account the pervasiveness of experiential avoidance in her life, as well as the kinds of consequences she’s experienced as a result of her control efforts. For example, a client who’s experienced a great deal of suffering due to control strategies might benefit from a metaphor in which control efforts make things worse, whereas a client who has mostly experienced a sense of meaninglessness or exhaustion as a result of control efforts might benefit more from a metaphor that captures this quality.
Ideally the metaphor will emerge naturally from what the client has already talked about; however, it’s useful to have a variety of established metaphors to pull from as needed. Examples include comparing the client’s situation to struggling to get out of quicksand (Hayes, 2005, pp. 3–4), working with a bad investment adviser (Hayes et al., 2012, p. 173), being on a hamster wheel that goes nowhere, or gambling on a rigged game. Another popular metaphor involves a person who gives meat to a tiger to make it go away, only to find the tiger returning hungrier, as well as bigger and stronger (Eifert & Forsyth, 2005, pp. 138–139). Many cultures have relevant stories that can be adapted to this purpose. Perhaps the metaphor most commonly used for this purpose in ACT involves a person who has fallen into a hole and has no tool for escape other than a shovel (Hayes et al., 2012, pp. 191–196). This metaphor shows that digging (representing control efforts) to get out of the hole doesn’t work but instead makes the hole larger. Clients are asked to examine their unworkable change agenda (i.e., the tools they use to get out of the hole and how they use them) and to notice that they are quite stuck. Ultimately, the goal is to drop the shovel and stop digging.
Acceptance or willingness is offered as the alternative to control. If a client can experience emotions, thoughts, and sensations from a chosen and open stance, then the function of those internal experiences is changed such that they no longer have the same degree of control over the client’s behavior. The personal costs associated with excessive control are reduced or eliminated. As therapy continues, images from the creative hopelessness metaphor can be referenced again when the client gets caught up in another control strategy. For example, the therapist can playfully ask, “Are you digging again?” or “Are you on the hamster wheel?”
In this section, we provide two dialogues demonstrating different strategies for undermining the control agenda. These dialogues provide examples of the process at two ends of the spectrum. The first demonstrates creative hopelessness with a client who has a long and pervasive history of experiential avoidance, as well as multiple experiences with previous treatments, and thus the process of undermining control is more intense, prolonged, and emotional. The second dialogue is a gentler, more tentative version with a client who has less of an attachment to and history with experiential avoidance, and who also has less experience of the costs of such behavior. Both of these dialogues involve clients with well-developed verbal skills. Therapists may need to simplify the process of undermining control and make it more concrete for clients who are less verbal or less abstract in their thinking. ACT should always be tailored to the client.
The first dialogue begins after the therapist and client have had a couple of sessions together and have formed a therapeutic relationship. They’ve already had discussions about the client’s values and how the client has tried to manage his anxiety. Earlier in the session, they spent some time building the client’s awareness of his experiential avoidance and examining workability. This dialogue picks up as the therapist is working toward identifying a metaphor to capture the experience. As you read the following dialogue, keep in mind that this is an example of how the creative hopelessness process might look on one end of the spectrum: what might be effective with a more pervasively stuck client who has a long history of treatment and for whom a more typical approach to therapy isn’t likely to be successful. This vignette also assumes that the therapist will work with this client in subsequent sessions, so this dialogue is only a preliminary step aimed at creating an initial opening to acceptance. (For clients who are more open to acceptance, the approach in the second vignette would be a better fit.)
We encourage you to see if you can identify the functions that are being targeted in the dialogue, rather than focusing on the content per se. We also encourage you to note any judgments or emotions that arise as you read through it.
Exercise:Learning from Your Reactions to This Dialogue
It’s common for beginning ACT therapists to feel apprehension at the thought of taking this kind of approach with a client. We invite you to see this as an opportunity to learn about your own psychological flexibility as a therapist. (We aren’t assuming that there’s any psychological inflexibility if you are anxious, as the presence of anxiety doesn’t necessarily mean you’d avoid it; rather, anxiety just sets the context for possible avoidance or fusion.) If you’re willing, we invite you take some time to explore your reactions to the dialogue, bearing in mind that the vignette is meant to serve as a model for how to foster acceptance.
As you were reading the dialogue, what were your reactions? Was it uncomfortable for you in any way? If so, how? What emotions did you notice?
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How about thoughts, particularly evaluations? Were there any parts of the dialogue that elicited judgments? What does your mind say would happen if you took an approach like that in the dialogue? What does your mind say it would mean if you chose not to take that kind of approach? How attached are you to any of these thoughts? How much do you see them as true or feel pulled to defend them, whether they’re “positive” or “negative”? Take some time to write about what you notice when you consider these questions.
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Some therapists, especially those new to ACT who can’t yet see how this fits into the overall model, respond to this vignette with a reaction of “I can’t (or won’t) do this to a client.” Sometimes this is followed by doubts about whether ACT is a good match for them or their clients. These are natural reactions, and they need not be a barrier to learning ACT. (They would only become a barrier if you were fused with them and felt a need to defend them.) If you noticed a reaction like this, we encourage you to consider treating this reaction as potential data about yourself—about your psychological flexibility and your values. We want to remind you that ACT is fundamentally about fostering choice and values-based behavior, including for the therapist.
While there is no ACT litmus test that demands “good” ACT therapists to use any particular technique, we want to explore the possibility that there very well may be certain contexts in which taking an approach like that demonstrated in the preceding vignette might align with your values. As such, you may arrive at a point, perhaps after learning ACT more thoroughly, when you choose to interact with a client in this way, even if doing so feels uncomfortable for you. If you are open to exploring this possibility, here are some additional considerations to explore.
What is painful for us is often linked to our values. If this vignette was difficult to read or consider, what might that tell you about your clinical work? What would you choose to have your work be about? Does this tell you anything about reorganizing your efforts to align with your values? Take some time to write about this now.
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Now that you have a sense of some of your values as a therapist, we ask that you reread the preceding vignette with an eye to how you might do something similar—in a way that aligns with your values. We also suggest that you practice awareness and willingness as you read it again to see whether you can get a feel for how the therapist’s methods might foster psychological flexibility, even if they could be interpreted as doing something else. Try to identify what might work to foster acceptance, and also notice what you evaluate as not working. As you write about these things, try to hold all of this lightly, seeing it as a process of learning about yourself and developing as a therapist.
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This exercise explored common therapist reactions that could result in hesitancy to use a method along the lines of that demonstrated in the vignette. If you found yourself relating to the vignette differently, with excitement or hope that using such methods will result in a magical change for your clients, we ask that you hold those responses lightly, as well. Sometimes dramatic or radical change can happen, and yet acceptance is a process. We encourage therapists to let go of a focus on outcome. Trying to change clients or get clients somewhere through this process runs counter to what acceptance is about. In addition, harboring an unspoken motivation of trying to have a client get the point is likely to come out in your behavior, which could result in invalidation, coercion, or sense of falseness. Remember that creating an opening for acceptance is about responding to the client’s actual experience, in the moment, as you perceive that experience based on the client’s history and present-moment reactions. This isn’t about getting anywhere other than where the client already is; rather, it’s about aligning with where the client already is. This work also isn’t about the therapist’s agenda for the client or what the therapist thinks the client should be doing. So if you find yourself trying to use these methods to coerce clients to be different, stop; you’re off track.
Deciding how much emphasis to place on undermining control largely depends upon the pervasiveness of experiential avoidance and control efforts in the client’s life. For some clients, experiential control has been their dominant way of living for many years, leaving them entrenched in this pattern; for others, experiential control is less pervasive, less practiced, or less dominant, so they may be more inclined to give it up as a solution. The more chronic and pervasive avoidance has been, the more likely it is that the therapist will need to emphasize creative hopelessness. When working with clients who have relatively less pervasive patterns of experiential avoidance, therapists can probably quickly move to helping them develop mindfulness and acceptance skills in the context of pursuing their values.
The following dialogue illustrates a brief approach to creative hopelessness that can be used in the latter case. The context is an early session with a bright, young, relatively functional client with social anxiety. Leading up to this dialogue, the therapist has reviewed the ways in which the client has tried to deal with his anxiety.
Therapist: Let me suggest something: If this were an easy, obvious problem to solve, you would have figured it out. (The therapist is supporting the client, noting that his failure to solve the problem isn’t because he is unable, but because it can’t be figured out.)
Client: I think so. Yeah.
Therapist: You’re a smart, capable person. You’ve been struggling with this a good portion of your life. And you know directly that there’s something inherently tricky about this problem. For example, even noticing that something isn’t there is enough to create it. It’s like, “Oh, I’m feeling better… Oh no…no I’m not.” Let’s look at what was on this list of things you’ve done to manage anxiety. There was distracting, reassurance, talking yourself out of it, avoiding it, and perhaps some other things we haven’t talked about yet. See if they all have this characteristic in common: They can, at certain times, be a little helpful… And ultimately they’re not that helpful. (Defines and names the control agenda.)
Client: Yeah.
Therapist: They don’t solve it.
Client: No. I know that. (Laughs.)
Therapist: And see if even this isn’t true: They can work for a short period of time, and they might make it worse in a moderate or longer period of time. For example, if you do something to distract yourself, sooner or later you have to check to see if it worked. And then when you check to see if it worked, it will remind you of what you were trying to forget… And then it’s back. (Points to the paradox of control efforts.)
Client: Yeah, sometimes I’ll be thinking, “Okay, I’m going to distract myself. Let’s think about something fun.” So I think, “Skiing, riding down the hill, getting to the lodge, hanging with friends at the lodge… Oh crap! Okay, start over.”
Therapist: Yeah.
Client: Or sometimes I’ll notice I’m feeling better, and then it will be back.
Therapist: Yeah. And here’s the problem: You talked about the tricks your mind plays on you. The problem is, your mind is in the room, not just you. So you’re doing a lot of stuff your mind is telling you to do. And yet it’s in the room, listening to what we’re saying.
Client: It knows. (Laughs.)
Therapist: Yeah. It knows what’s going on, right?
Client: Yeah.
Therapist: But it doesn’t seem to be able to give you ultimate, final answers. If anything, it seems to torment you. It reminds you of some random memory you don’t want to think about.
Client: And I can’t logically make it go away. I think I understand what you’re saying. I know what I’m thinking isn’t logical, but it just doesn’t get through.
Therapist: Right, because this isn’t just a logical deal, it’s a psychological deal. And that’s not the same thing. So let’s put these things together. We need to carve out some space here in which to work. I want you to consider the possibility that you’ve pretty much exhausted the things that seem logical, reasonable, or sensible. They pay off like this. (Spreads hands toward client, making a gesture that implies that it hasn’t worked because the client is here, in therapy, looking for ways to control anxiety.) They don’t pay off in some other way.
Client: (Laughs.) No, they don’t.
Therapist: They pay off like this. And if that’s the case, then we’re going to have to open up the possibility that a whole other approach is needed. And yet we’ve got a mind in the room that will say, “Oh yeah, I get that,” and try to pull whatever we do back into the same system. (Pauses.) So, you know what quicksand is, right?
Client: Yeah.
Therapist: When people step in it, they do the normal, logical, reasonable, sensible thing: they try to get out of it.
Client: Which makes it worse.
Therapist: Yeah. The normal way to get out of things is to push to get out. The problem is, when you do that with quicksand, it just sinks you in deeper. Pushing on the one foot didn’t work, so you push on the other. Now you’ve got two of them in there. Maybe it’s like that. Maybe the things you’ve been doing are like the normal, logical, reasonable, sensible things people do when they are stuck in quicksand. And in fact, it’s not liberating you; if anything, it’s making you more stuck. So if that’s true, we have to find something that might work that’s outside the set of all the things that might work. (Here, the therapist has included some defusion in the metaphor.) You know what I mean?
Client: (Laughs.) Yeah. (Pauses.) So, what are we going to do, then?
Therapist: (Pauses and smiles.) Well, your experience is telling you, “I do something, and it doesn’t pay off. It pays off short term and it doesn’t pay off long term.” (The therapist is reflecting the client’s experience of workability.) And really, the problem just keeps hanging around. Sometimes it’s better and sometimes it’s worse, but here it is. And you’re trying not to let it grow. But it’s still here, and you’re stuck.
Client: Yeah.
Therapist: Well, I want to open the door and say, “You know that sense you have that you’re stuck? Well, maybe you have that because you really are stuck.” This game is a stuck game. It’s not going to work some other way. It works like this. You know in your experience how things have worked. If you back up and look at it, it almost seems like this is a rigged game. In other areas of your life, you put in the effort and get the outcome. Not here. So we’ll need to do something really different.
Ultimately, the idea in creative hopelessness work is to validate clients’ actual experience of control not working, to validate the emotions they’re experiencing, and to suggest that the social messages they’ve been given might be incorrect, rather than that clients are incorrect. So before the end of a session like this, be sure to establish that you’re suggesting that the agenda is hopeless, not that the client is hopeless. Also, note that the “creative” piece in creative hopelessness refers to an openness that comes when clients finally abandon needless experiential control and turn their attention to living a life that aligns with their chosen values. After all, the goal is not to create a feeling of hopelessness or belief in hopelessness; in fact, this process often creates a hopeful feeling. The goal is simply to speed the process of abandoning what isn’t working (Hayes et al., 2012).
When clients fully contact the unworkability of old control agendas, they may feel lost or confused because the path they’ve been on no longer seems viable. This isn’t a negative sign; it’s a sign that old control behaviors are beginning to fall away. Occasionally, clients might feel upset or angry at this point, with a sense that they’ve been tricked by life or by the clinician. If so, you might validate this saying something like, “It makes sense that you’d feel upset after putting so much effort into something with so little payoff.” In order to forestall potential self-blame, you might say, “It isn’t your fault that you fell into this hole. These were the tools you were given by society. But what if it’s the case that much of what we’re taught to do with our painful emotions and thoughts can actually make things worse? What if it’s the case that the things your mind tells you to do might actually get you more stuck?” Other common reactions, which may not require a specific response, include clients slowing down or being more thoughtful, periods of silence, a sense of lightness in the room, laughter, and a start-and-stop quality to clients’ speech, as if they’re catching habitual patterns of thinking.
Because creative hopelessness is such an important piece of both the up-front and the ongoing work in ACT, and because it typically begins early in therapy (and appears early in this book), we have additional key guidelines to share. A common mistake on the part of therapists is trying to convince clients that avoidance isn’t working or that they must give up their agenda of experiential control. Another is that therapists may try to push clients further than they’re currently ready to go. It’s essential that the client’s experience be the absolute arbiter. Creative hopelessness will only function as it should if the confrontation is between the client’s system of experiential control (the mind) and the client’s actual experience, not between the therapist and the client. The therapist is simply there to guide the process of helping clients examine their own experience and determine whether the solutions their minds have been putting forward have actually worked as they were supposed to, or whether their experience has shown otherwise.
Another common therapist misstep at this point is getting caught up in the content of what clients say. For example, therapists may assume that a seemingly logical or healthy solution should be supported, without exploring its actual function. In this case, a therapist might encourage a depressed client to exercise more (a seemingly healthy behavior in depression) without knowing whether exercise functions primarily as avoidance for that client. So remember that the target of acceptance is undermining behaviors that serve as experiential avoidance, which is defined based on function, not form. In the example of exercise, a psychologically flexible route forward might involve either more exercise or less—more if this behavior is linked to values, and less if it’s linked to avoidance. Responding based on content is especially tempting if strategies the client has tried are similar—in form—to ACT methods (e.g., mindfulness meditation). However, the purpose is not to endorse formally correct methods; it is to explore the functional impact of any and all solutions and let go of anything that isn’t working. Typically, what isn’t working is clients’ cognitive entanglement with their mind and the resulting control agenda, which may not be easily seen or logical. Clients’ experience is the biggest ally in determining the function of their behavior.
Finally, we want to be clear that creative hopelessness isn’t about a one-time, all-or-nothing shift in behavior; it’s about establishing the possibility of an approach other than control—in this moment, the next moment, and then the next moment. It’s about helping clients see that each moment of existence offers an opportunity to say yes to their experience, feeding the vitality of a values-based life, rather than continuing down the path of experiential avoidance.
In the preceding dialogue with the client who had less of an attachment to experiential avoidance, you can see the therapist transition from working on the sense of creative hopelessness to more explicitly outlining how experiential or emotional control might be part of the problem, rather than the solution to the client’s current difficulties. Many clients come to therapy believing they need more control over their internal experience. However, misapplied control has already landed them in an unworkable agenda—and it’s done so at the expense of their lives; they’ve put their lives on hold while they worked on getting their emotions or thoughts under control.
All therapists have heard clients make statements such as “When I get my anxiety under control, I’ll get a job,” “When the pain stops, I’ll find another relationship,” or “When I don’t feel guilty anymore, I will reconnect with my children. I don’t want to subject them to my guilt.” These kinds of statements come in all shapes and sizes, but all versions are about the client beginning to live only after unwanted internal experiences are under control. Of course, the problem with this is that life occurs in the present moment. And as should be clear at this point, it’s difficult to change what happens internally in any lasting and meaningful way. It’s more likely that efforts at control will lead to more problems and costs. This can happen in obvious ways; for example, perhaps a client drinks heavily to avoid feeling sad. It can also play out in more subtle ways. Imagine a client who tends to change the subject whenever you begin to talk about painful issues yet desires more intimate communication with others. The following dialogue points to this issue.
Therapist: So you had a good time this weekend at the lake?
Client: Yes, it was a lot of fun. I hiked and went swimming. I really got to take a break… But I was alone, and that was kind of a bummer.
Therapist: You were alone? I know it’s been hard for you to be alone. Was it painful?
Client: Yes, but you won’t believe what happened when I was hiking. I came across a bear on the side of the trail…
Therapist: (Interrupts.) I noticed that you skipped past that painful part.
Client: Yeah, but I wanted to be sure and tell you about the bear.
Therapist: It seems it just happened again. What do you think would happen if you showed up to the pain?
Client: (Gets tearful.) I’d start to cry, and I don’t want to do that.
Here you can see how the client is avoiding vulnerability at the expense of intimacy. The therapist’s goal in such cases is to point out the costs of this kind of control: loss of values-based living. For this client, those costs include loss of intimacy, connecting, and lovingly participating in relationships.
Misapplied control efforts can be tackled by an appeal to clients’ experience, just as described for creative hopelessness, and by using metaphors that model the problem of control. An often used metaphor is the Tug-of-War with a Monster (Hayes et al., 2012, p. 276), wherein the therapist and client engage an experiential exercise demonstrating the struggle with difficult emotions and thoughts by engaging in a mock tug-of-war. The therapist typically pretends to be the negative emotions and thoughts that the client would like to eliminate, while the client plays himself. The two pull on opposite ends of a rope (perhaps using a real rope as a prop), stretched between them over an imagined bottomless pit that represents what appears to be certain destruction if the client is unable to defeat the negative experiences by pulling them into the pit. During the exercise, the therapist works with the metaphor in such a fashion that the client experientially contacts or sees that this war is not being won (e.g., the difficult emotions remain). Tugging to win is equated with control. Clients often eventually realize that the only solution is to let go of trying to win the war—to drop the rope. In some cases the therapist may need to point this out. The emotions and thoughts don’t disappear when the client lets go, but there is no longer a battle and the client is freer to move.
The ACT literature has many other exercises and metaphors that demonstrate the problem of control: the Polygraph metaphor (Hayes et al., 2012, pp. 182–183); the Chocolate Cake task (Hayes et al., 2012, pp. 185–186); the Feeding the Tiger metaphor (Eifert & Forsyth, 2005, pp. 138–139); the Chinese Finger Trap metaphor (Eifert & Forsyth, 2005, pp. 146–149); and many others (Stoddard & Afari, 2014; Harris, 2009, pp. 89–95). Each illustrates the paradox of control: the more you try to control your internal experience, the more you lose control.
This paradox is captured by the message “If you aren’t willing to have it, you’ve got it” (Hayes et al., 2012, p. 185), or its variant, “If you aren’t willing to lose it, you’ve lost it.” If you aren’t willing to have anxiety, then anxiety is something about which to be anxious, leading to even more anxiety. If you’re not willing to lose love, then you can’t have love because you will constantly be trying to control your beloved.
Those examples are focused on experiential control related to emotions, but this paradox also applies to thoughts. If you try to control what the mind is thinking, an immediate problem arises: you have to contact what you’d like to control in order to know that you want to control it—and in order to try to do so. To help clients understand this, you could ask them not to think about a banana for thirty seconds, for example. Of course, many immediately think about a banana. And the harder they try not to think about a banana, the more they will be thinking “banana,” and then perhaps about banana splits, the color yellow, bunches of bananas, and so on. Some clients will report that they were able to distract themselves. Exploring what they did to accomplish this can usually show that there are significant costs to distracting themselves from thoughts about bananas. Distracting ourselves might work in the short run, but it results in a narrowing of awareness (i.e., we can’t think about anything related to bananas) and it takes energy, leaving us less free to focus on what we’d most want to—for example, our values. You can then discuss how this effort is likely to backfire when applied to thoughts that seem particularly important to control. And indeed, it has backfired; otherwise, the client wouldn’t be complaining about having difficult thoughts. Of course, the aversiveness of thinking about a banana is probably miniscule for most people. However, other thoughts can have a strong impact—thoughts like “I’m damaged goods,” “There’s something wrong with me,” or “I’ve wasted my life.” Clients often want to get rid of these kinds of weighty thoughts, yet distracting themselves from these thoughts will be much more difficult or costly.
Once you’ve explored workability and established control as the problem, you can turn to helping clients practice willingness. Occasionally, clients will already be open to this, in which case you can jump right to practicing willingness, as we’ll describe shortly. However, many clients are hesitant, often because they are unclear about what willingness is, in which case you’ll first need to teach them what it is. Where you start with a client is determined by your conceptualization of the case (see chapter 8).
In the following dialogue, the therapist returns to the Quicksand metaphor, but this time for a slightly different purpose: as a way to begin to point to what willingness is like.
Therapist: Do you remember the metaphor of falling into quicksand?
Client: Yeah. The harder I try to get out, the faster I sink?
Therapist: Exactly… The harder you try to get out, the faster you go down. We didn’t talk about what to do when you get stuck in a situation like this—besides struggle. With quicksand, in order not to sink, what you need to do is the opposite of what you’d naturally think to do. In order to stay afloat in quicksand, you have to gently spread out and let as much of your body contact the sand as possible. (The therapist slowly opens her arms to emulate spreading out in quicksand.) The more of your body you place in contact with the surface of the quicksand, the more you’ll float and not drown. What if getting rid of anxiety is like falling into quicksand? The harder and faster you try to get out of it, the more you sink into it and the worse things get. Maybe the thing to do is to stop struggling—to get in contact with the emotion and learn to float in it. (The metaphor allows the therapist to point to willingness in a way that’s simple and intuitive, rather than getting caught up in complex descriptions. It also points to willingness as an alternative through the notion of floating in a feeling.)
Client: But floating in it doesn’t get me out of it either.
Therapist: That’s right. What you feel is still there to be felt, even as you let go of the struggle that makes things worse. Is that something you’d be willing to do if it meant you wouldn’t drown?
Client: Do you mean I have to float in order for the anxiety to go away?
Therapist: Two things: First, you don’t have to float; this is your choice about how you’ll be with your anxiety. And second, floating in quicksand isn’t about the anxiety going away… Spreading out in quicksand doesn’t make it stop being quicksand. Trying to spread out in order to get out isn’t spreading out; it’s a tricky way to struggle. Your mind is with you all the time and knows what you’re doing, so it will have the same quality as struggling. (The therapist is pointing out that willingness is chosen, and that anxiety will feel like it feels. It’s important not to get wordy at this point and overexplain. Letting the metaphor stand without additional explanation is likely to be more effective.)
Client: (Sounds disappointed.) But I don’t want to float in quicksand.
Therapist: (Speaks from a grounded and humble stance.) Of course you don’t. Who wants to be anxious? And yet what if this is the choice life is giving you? You’ve fallen into the quicksand. Struggle and get more stuck, or spread out and float? It’s a choice, an action. I’m not sure either of us knows what will happen when you float. But you do know what happens when you struggle, because that’s what you’ve been doing up until now.
Client: Yes, but how do I float?
This is just one example of how to introduce the idea of willingness as an alternative to control efforts. This opens the door to shifting the work to an explicit focus on building new behaviors that are about embracing, holding, and compassionately accepting one’s experience. Clients usually enter therapy with an agenda of wanting to feel better. Acceptance is the work of helping them feel better—meaning to get better at feeling (Hayes et al., 2012)—in the service of living better. In this part of therapy, the clinician’s job is to guide clients in practicing willingness in various contexts, with various private events, and with the goal of developing the ability to apply it broadly in their lives. However, clients are generally unsure what will happen if they’re willing to experience their emotions. Letting go of control of internal events can and does feel like taking a step into the unknown—almost like closing your eyes, taking a step, and hoping that your foot finds the ground.
As you explore what willingness is with clients, there are two key points to elucidate: that willingness is a choice, and that willingness is an action.
“Choice” means making a selection simply because we can. Therefore, the choice to be willing is present in every moment. Often clients assume that they don’t have a choice and list several if not many reasons they can’t choose to be willing. You can work with such clients to help them defuse from or observe their reasons and still take action. There are a couple of quick ways to demonstrate this for clients. One is to give them a choice between two similar objects. For instance, you might ask clients, “Tea or coffee, which would you choose?” After they’ve made a choice, ask them to generate as many reasons as possible to explain why they made that choice, and stick with this until they’ve listed a fair number of reasons. For the purpose of this explanation, let’s assume that a client chose coffee. Then, no matter how good the client’s reasons, such as “I’m allergic to tea” or “The taste of tea makes me sick,” ask if it isn’t true that the client could still choose tea and drink it, despite all the reasons generated. The answer is, indeed, yes. It is not the reason that chooses, but the person. You can then bring this back to the larger issue at hand by asking, “Would you be willing to choose willingness if it meant you got to live your life?”
The metaphor of an annoying neighbor (inspired by the Joe the Bum metaphor; Hayes et al., 2012, pp. 279–280) can be useful in this type of situation.
Therapist: Imagine you’ve just purchased a new home and you decide to hold an open house. You make invitations that say, “All are welcome,” and post them around the neighborhood. You’re excited about the party and begin to get ready by making everything look nice and by preparing the food and drinks. The big day comes, and everything is going well. The guests are arriving and enjoying themselves; everyone is laughing and having a good time. More guests are arriving. Then you hear a knock at the door. You open it with a smile, which rapidly changes to a look of distress. There before you stands Edna, a neighbor you’ve already found quite annoying. Edna makes obnoxious noises, is often rude to people, and has terrible manners. You quickly try to close the door, but Edna has placed her foot between the door and the jamb, so you can’t close the door. You ask her to leave, but she shakes her head and shows you one of the invitations you posted around the neighborhood. She repeats the words written in large letters: “All are welcome.” She tells you that she’s not leaving and will stand right there until you let her in. Given the situation—that she’s not leaving and you aren’t interacting with your guests—you decide to let Edna in, but you insist she needs to stay away from the guests and remain in the kitchen. You rapidly escort her to the kitchen and admonish her to stay there. You close the door to the kitchen and begin to walk away…and right behind you is Edna. She follows you out of the kitchen. You turn and say, “No, Edna, you must stay in the kitchen,” and escort her back. Once again, you turn to join the party, and…guess what happens.
Client: Edna comes pushing through the door again.
Therapist: Right. And what you find is that you have to stay in the kitchen with your foot propped against the door to keep Edna out of sight. You’re locked in. What’s the problem here?
Client: I don’t get to be at the party.
Therapist: Yes. So, the big question is, would you be willing to let Edna wander around the house if it meant you got to be at the party too?
Client: It would be hard.
Therapist: Yes, but could you choose to do it and be at your party?
Client: Yeah, that’s what I’d want to do.
Working with clients in this area boils down to a single question, “Are you willing to feel what you feel, have the thoughts you have, and let your sensations be there, fully and without defense, and do what works for you according to what you value?” Though the answer may seem simple and clients often say they are willing, the path is potentially difficult. Clients may continue to struggle, getting entangled in reasons and losing the distinction between mind and self. When this happens, they may lose the experience of being able to choose. The intensity of thought and emotion that may arise when they’re presented with values-based choices in the presence of negatively evaluated emotions may pull them back into a struggle. In ACT, the therapist’s job is to keep pointing to willingness and choice, linking them to values, and supporting clients’ efforts to take a stance of open engagement in the process of living. At the same time, the therapist validates and empathizes with the client’s experience in taking on this challenge.
Throughout this chapter, we’ve provided multiple descriptions of willingness. Willingness isn’t a feeling, and it isn’t something that can be directly instructed or described, just as you can’t directly describe how to ride a bicycle, play a musical instrument, or perform a highly skilled sport. This aspect of willingness can be captured, for some, by comparing willingness to something that happens when skiing.
Therapist: Have you ever gone skiing?
Client: Yeah, a few times.
Therapist: Have you noticed how, when you’re skiing and you’re afraid you’re going too fast, your natural tendency is to lean away, to lean back into the hill? The problem is, as soon as you do that, you lose control of the direction in which you’re headed, and in fact, you even increase the chance that you’ll wipe out. In this situation, the natural response—to lean back—doesn’t work very well. What if this situation in regard to your thoughts and feelings is similar? What if the natural reaction—to lean away from your own experience—is actually part of the problem? What if what’s needed here is to practice leaning downhill, leaning into your experience, so you can have more control over where you’re headed in your life?
Having established what willingness is, the next step is to assist clients in practicing willingness, shaping their progress by recognizing and reinforcing even small acts of willingness. Ideally, willingness is practiced throughout therapy and is interwoven with all the other flexibility processes. For example, any time an ACT therapist asks a client to do an exercise or discuss a topic that might evoke difficult content, this provides a chance for the client to choose between willingness and struggle.
In-session and out-of-session exercises can be used to structure opportunities for clients to practice willingness. For examples, see chapter 7 (committed action) or exercises in other books, such as the Looking for Mr. Discomfort exercise (Hayes et al., 2012, pp. 285–296) or exposure-like exercises (see Eifert & Forsyth, 2005). It is worth noting here that, from the ACT perspective, exposure work isn’t done in the service of reducing fear (i.e., for habituation). Rather, it is engaged as a process of helping clients practice willingness to contact uncomfortable experiences without struggling against them (see Thompson, Luoma, & LeJeune, 2013). Such practices can be utilized at any time in treatment, as long as they are flexibly applied and responsive to the context or situation of the client.
ACT willingness exercises often take the form of in-session exposure exercises in which difficult material is elicited, and then therapist and client work with this material together in session (for more on this topic, see chapter 7). And although willingness tends to have an all-or-none quality, the context in which willingness is practiced can be chosen, at least in part (Strosahl, Hayes, Wilson, & Gifford, 2004). For example, clients can choose to be willing for five seconds or for an hour. They can choose to be willing in a mall but not in a bookstore. They can work on willingness with one emotion but not another. Because clients can choose the situation (but not the level of willingness), the therapist can titrate willingness work to the client’s current situation and context. And just as therapists conducting exposure typically create an exposure hierarchy, ACT therapists usually encourage clients to start with small acts of willingness, perhaps for a few moments in a session or with relatively unchallenging private events. They can then move to larger acts of willingness, such as calling an estranged sibling and willingly feeling whatever shows up during that call.
Clearly, willingness or acceptance is a process and not an outcome, and it’s so foundational that it is integrated into all aspects of ACT. It isn’t as if clients “get willing” and their work is finished. There is always more willingness to do—in life and throughout the course of treatment.
This isn’t fully possible without the other flexibility processes. However, at this point in the book we can only provide a broad overview of the application of acceptance that occurs later in therapy. Because willingness involves embracing the moment as it unfolds in the here and now, willingness is an important subtext when working with present-moment awareness, which is discussed in chapter 4. And because willingness is a choice that entails letting go of fusion with reasons while simultaneously selecting among alternative courses of action, the fully developed form of willingness incorporates defusion as a necessary component, as discussed in chapter 3. Willingness also interacts with self-as-context, discussed in chapter 5, as contact with self-as-context, a safe place that transcends one’s experience, facilitates willingness. Having a larger sense of self that transcends emotions, thoughts, and sensations allows people to contact the broad set of experiences they encounter in life without the need to control or eliminate those experiences. Furthermore, willingness to experience difficult thoughts and feelings is generally done in the service of values; this is part of what makes willingness different from wallowing. We’ll explore this further in chapter 6. Finally, willingness is key to committed action, so chapter 7 includes important strategies for bringing willingness to this process.
Core Competency Practice
This section is intended to provide practice in working with willingness in response to sample dialogues based on ACT sessions. There is one exercise for each of the eleven ACT core competencies for willingness and acceptance. For each, we present a description of a clinical situation and a brief dialogue. (Some of the dialogues continue across multiple competencies.) Most of the dialogues also include other elements of the ACT model because a single process is seldom used in isolation. Each dialogue ends after a client statement, at which point we ask that you provide a response that reflects that competency. Then we ask you to describe the basis for your response. For each exercise, focus on providing a response that illustrates the target competency, rather than responses that are consistent with ACT in general. You can also describe any steps as part of the response that would contribute to implementing the competency most effectively. After you provide a response and your explanation, turn to the end of the chapter, where we provide model responses that you can compare your response to, typically two for each exercise.
The model responses are not the only correct responses, and we don’t offer them as perfect or ideal responses. Often there may be scores of well-conceived ACT-consistent alternatives. Our main purpose in providing models is to give you a sense of what a high level of competency might look like. If your response aligns with one of the models, that’s an especially good sign. If your response seems to fit the explanation and competency just as well as the models do, you’re doing fine. If you think the model responses might be more powerful than your response, try to learn from them. If you don’t understand the model responses or they suggest that your response is off track, reread the relevant portions of this chapter or consult other texts.
We strongly recommend that you not read the model responses until after you’ve written your own response. Coming up with your own responses first creates the greatest opportunity for learning and allows you to maximally benefit from the feedback inherent in the model responses. If you really want to stretch your flexibility, you can write multiple possible responses before looking at the samples.
Before you get started, we’ll offer the following example of how you might complete one of these exercises.
Competency 2: The therapist helps clients make direct contact with the paradoxical effects of emotion control strategies.
Completed Sample Exercise
The client is a nineteen-year-old female college student who complains of social anxiety and a general lack of color or excitement in her life. She feels that this is related to her childhood history of sexual abuse. Through therapy, she’s been able to see how memories of the abuse surface when she finds herself feeling close to people. In response, she distances or numbs herself. This dialogue occurs in her sixth session.
Therapist: So, let me see if I get the sequence. You’re sitting around with your boyfriend; he touches you; you start to feel anxious and really unsafe; and then you feel ashamed that you feel that way. Right? Then you find some excuse to get out of there and go home and drink so you don’t have to think about it. Is that the sequence?
Client: Yeah, I just can’t think about it. It’s too hard. I’m so tired. I just need a way to get over this.
Write here (or in a notebook) what your response would be, keeping in mind that the focus is on competency 2:
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Therapist: If talking about this experience could make it possible for you to have the open, loving relationship you so want, would you be willing to do that?
Client: Yes.
Therapist: So let me ask you then: The more and more you’ve tried to make these anxious and guilty feelings go away, what have you found? Have they decreased over time, or have they perhaps even gotten stronger, and in the meantime you still find yourself feeling distant, lonely, and cut off?
In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?
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Her avoidance clearly isn’t working given what she wants in life. I’m linking up this issue with her values and getting permission to talk about what’s likely to be a painful and sensitive subject, one in which the client might feel challenged and perhaps even intruded upon. Then I’m having her check out whether this strategy has actually worked out the way it was supposed to, or whether perhaps it has, paradoxically, made things worse.
(After writing your own response, you would then check it against the models at the end of the chapter before going on to the next exercise.)
Competency 1: The therapist communicates to clients that they are not broken but are using unworkable strategies.
Exercise 1
A fifty-six-year-old man has come to therapy seeking relief from anxiety associated with PTSD. He has been in a number of treatment programs and worked with at least three other therapists and two psychiatrists. He complains that he can’t do regular, everyday kinds of things because his anxiety is too high. He isolates himself and wishes things were different and also uses other avoidance strategies. Just prior to the start of this dialogue, the client has listed about ten strategies he uses to get rid of anxiety.
Client: What I’d really like to do is find a way to get this anxiety under control.
Therapist: It seems you’ve tried a lot of different things. You’ve certainly made an effort.
Client: Yeah, I just need to try harder…to figure out what will make this different.
Write here (or in a notebook) what your response would be, keeping in mind that the focus is on competency 1:
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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?
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Competency 2: The therapist helps clients make direct contact with the paradoxical effects of emotion control strategies.
Exercise 2
This dialogue continues where the dialogue for competency 1 left off.
Therapist: So trying harder seems like the thing to do. But haven’t you tried hard in the past? You’ve gone to treatment programs, therapists, and psychiatrists. You’ve listed numerous things you’ve tried. You’ve tried hard, yes? Look at your experience. What do you know from there (points to the client’s heart) and not there (points to the client’s head)? What does your experience say about the results of trying hard?
Client: It hasn’t worked so far.
Therapist: Right. And what if that’s because it can’t? What if you really did give it a good attempt, but this is how trying hard actually works in this area? (Points to the client’s chest again.)
Client: I see what you mean, but I just want things to be different. I’m feeling anxious all the time. I can’t stand being like this.
Therapist: If things were different with your anxiety, what would you be doing?
Client: Everything would be different. I’d be able to be around people. I could work. Everything would be a lot better.
Write here (or in a notebook) what your response would be, demonstrating competency 2:
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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?
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Competency 3: The therapist actively uses the concept of workability in clinical interactions.
Exercise 3
This dialogue continues with the same client as in the competency 2 exercise but occurs later in the session.
Therapist: How successful have you been at making things different when you try harder?
Client: Well, it works for a little while, and then the problems start all over again. The anxiety comes back.
Write here (or in a notebook) what your response would be, demonstrating competency 3:
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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?
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Competency 4: The therapist actively encourages the client to experiment with stopping the struggle for emotional control and suggests willingness as an alternative.
Exercise 4
A forty-one-year-old woman is seeking therapy to alleviate anger and sadness around the breakup of a relationship. The breakup occurred three years before she entered therapy. In her initial session, the client explained that she feels betrayed and unable to move past the pain of the breakup. She notes that her anger is interfering with her ability to move on. She also notes that she’s angry with herself for being duped in the relationship. This dialogue occurs in her fourth session.
Client: I feel overwhelmed by my anger…and I feel stupid. It’s been three years. Why can’t I get over this? It’s embarrassing.
Therapist: Somehow getting over this seems like the thing to do, and then embarrassment and “stupid” will go away, in addition to the anger?
Client: Silly, isn’t it?
Write here (or in a notebook) what your response would be, demonstrating competency 4:
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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?
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Competency 5: The therapist highlights the contrast between the workability of control and willingness strategies.
Exercise 5
For this exercise, assume you have the same client as in the exercise for competency 4, but the session goes like this instead:
Client: I feel overwhelmed by my anger…and I feel stupid. It’s been three years. Why can’t I get over this? It’s embarrassing.
Therapist: Somehow getting over this seems like the thing to do, and then embarrassment and “stupid” will go away, in addition to the anger?
Client: Silly, isn’t it?
Therapist: I can see you have a lot of judgment about your anger. You think it’s silly and stupid.
Client: It is. I just can’t believe I’m still angry about this. It doesn’t make any sense to me.
Write here (or in a notebook) what your response would be, demonstrating competency 5:
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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?
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Competency 6: The therapist helps the client investigate the relationship between willingness and suffering.
Exercise 6
This dialogue continues with the same client as in the exercise for competency 5 but occurs later in the session.
Therapist: What kind of effort have you put into making the anger go away?
Client: A lot. I can’t even begin to describe how hard it’s been.
Write here (or in a notebook) what your response would be, demonstrating competency 6:
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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?
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Competency 7: The therapist helps the client make contact with the cost of unwillingness relative to valued life directions.
Exercise 7
This dialogue continues where the dialogue for competency 6 left off.
Therapist: What are some of the things that have happened because of this difficulty? How has your life changed as a result of how hard this has been?
Client: Well, I’m suspicious of men. I think they’re all trying to pull the wool over my eyes. I’ve stopped dating completely. I tried it a couple of times, but found myself being cranky on the dates. I’m incredibly lonely and feel angry at men… I blame men for that. I’m just out of control about men… How can I ever trust them?
Write here (or in a notebook) what your response would be, demonstrating competency 7:
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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?
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Competency 8: The therapist helps the client experience the qualities of willingness.
Exercise 8
This dialogue continues with the same client as in the exercise for competency 7 but occurs in a later session.
Therapist: How important is it to you to have another relationship?
Client: I would really like one, but I just don’t think it’s possible. Something really significant would have to change.
Write here (or in a notebook) what your response would be, demonstrating competency 8:
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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?
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Competency 9: The therapist uses exercises and metaphors to demonstrate willingness as an action in the presence of difficult internal experiences.
Exercise 9
A fifty-year-old man is in therapy because his wife has insisted he get help for his withdrawn and irritable style of interacting with her. He reports that he feels distant from his wife and has wanted her to leave him alone ever since a misunderstanding that resulted in a financial loss. He notes that he’s extremely disappointed in his wife, even though he recognizes that the financial loss was not her fault.
Therapist: What would you choose to have happen with this relationship? Are you wanting it to end?
Client: No, I don’t want a divorce or anything like that. I just can’t bring myself to talk to her. I almost can’t even look at her. I know that losing the money wasn’t her fault, but I still blame her. I want the money back.
Write here (or in a notebook) what your response would be, demonstrating competency 9:
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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?
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Competency 10: The therapist models willingness in the therapeutic relationship and helps the client generalize these skills outside therapy.
Exercise 10
This dialogue continues with the same client as in the exercise for competency 9 but occurs later in the session.
Client: I am ashamed that I’m so focused on the money. It’s hard to admit. I’m worried that you might think I’m an asshole.
Therapist: It’s hard to admit these things. It can be anxiety provoking.
Client: Yeah, I’m having a hard time talking about it with you… I’m not sure you can help.
Write here (or in a notebook) what your response would be, demonstrating competency 10:
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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?
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Competency 11: The therapist can use a graded and structured approach to willingness assignments.
Exercise 11
This dialogue continues with the same client as in the exercise for competency 10 but occurs later in the session.
Client: I don’t even know where to begin. It’s like, now that I’ve started ignoring her, I can’t find a way to stop. I feel like it’s impossible to get out of this.
Therapist: It seems like even a small gesture toward your wife feels hard.
Client: Just looking at her feels hard.
Write here (or in a notebook) what your response would be, demonstrating competency 11:
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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?
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Core Competency Model Responses
Competency 1
Therapist: Another way to say what you just said is “I’ve got to try trying harder.” Have you tried to try harder before?
Client: Sure. And harder, and harder.
Therapist: So, I want you to consider that maybe the problem here isn’t that you haven’t tried hard enough. Maybe the problem is something about the tools you’ve been given by society, by your parents, and by your history—the things you’ve been taught to do to deal with this. Maybe they just don’t work here. It’s as if you’ve been trying to use a hammer to paint a masterpiece. Now I’m also not saying I have a different, better tool, because you’ve done that, too—looked for a better tool. This trap you’re in is trickier than that.
Explanation: It’s important for the therapist to openly recognize that control of internal experience is a socially trained phenomenon. It isn’t the client’s fault that he would try such a maneuver. He’s been taught by his social/verbal context that he should be able to solve the problem of anxiety. He’s been taught that these maneuvers should work. Trying harder is just another part of that social/verbal context, as evidenced by sayings like “If at first you don’t succeed, try, try, again.”
Therapist: So trying harder seems like the thing to do. But haven’t you tried hard in the past? You’ve gone to treatment programs, therapists, and psychiatrists. You’ve listed numerous things you’ve tried. You’ve tried hard, yes? Look at your experience. What do you know from there (points to the client’s heart) and not there (points to the client’s head)? What does your experience say about the results of trying hard?
Client: It hasn’t worked so far.
Therapist: Right. And what if that’s because it can’t? What if you really did give it a good attempt, but this is how trying hard actually works in this area? (Points to the client’s chest again.)
Explanation: Here the therapist validates the client’s effort while pointing to the fruitlessness of this effort. ACT therapists don’t ask clients to believe these efforts are fruitless because the therapist says so; rather, clients are asked to examine their own experience to see whether these efforts have paid off. These kinds of statements aren’t made in an attempt to gain a one-up position in relation to the client or to shame the client for trying hard and failing. In this response, the therapist simply points to a system that doesn’t work, from a humble stance.
Competency 2
Therapist: I see that these things are important to you: to work and have people around you. It seems like getting control over the anxiety is the route there. But something seems strange here. You’ve been working at trying hard to control your anxiety for quite some time, and as far as I can tell, things haven’t turned out as you’ve hoped. In fact, here you are, sitting in front of me seeking yet another way to make your anxiety go away—to make your anxiety different. And these things you hope for—work, relationships—aren’t getting closer.
Explanation: The therapist states that something is strange, as if to say this isn’t the client’s fault but the way it works is odd. This is a relatively defused contact with workability. The therapist also points out that the client seems to be doing the same thing he’s done in the past: work with a therapist to come up with yet another strategy for eliminating anxiety. This statement points to the paradox inherent in control efforts. This can be a tricky place for the therapist, who probably feels a pull to rescue the client and reassure him that there is a way. However, this would be premature at this point and would undo the effects of contacting the unworkability of control.
Therapist: Do you see what’s happening here? Here you are working to make your anxiety go away, but it stays. In fact, it seems that if you don’t want it, you’ve got it. If you don’t want your anxiety, you’re going to get anxiety. In fact (speaks somewhat playfully), not being able to get rid of your anxiety is something to be anxious about. In your experience, as you’ve worked on this has your problem seemed to be getting larger or smaller?
Explanation: The therapist shares an idea with the client that reflects the paradox of control—that if you don’t want it, you’ve got it—and asks the client whether this fits with his experience. Appealing to the client’s experience is particularly important here. None of what the therapist says should come across as an effort to convince the client about the problems with control. Convincing is content heavy and moves clients away from the experience that everything they’ve tried hasn’t worked. Here, the therapist directly points to the issue of what the client’s experience says about how control has worked for him in reducing his anxiety over time.
Therapist: In your experience, has there ever been a significant amount of time when you didn’t experience anxiety?
Client: No.
Therapist: Is this struggle with anxiety opening up your life or closing it down?
Explanation: One of the goals of ACT is to help clients move toward a workable agenda that’s guided by their values. Clients can actively bring willingness to taking steps intended to build a better life. Again, workability is about living better, as defined by the client, not necessarily feeling “better.”
Therapist: You’ve hired me. So I’m here to work for you.
Client: Yeah, I guess.
Therapist: Is part of my job to tell you what I see?
Client: Yeah. What do you see?
Therapist: From what you’ve told me, you’ve done many if not most of the reasonable, sensible, logical things you could do to get your anxiety under control. You’ve worked very hard and tried many, many sensible and reasonable options. But something seems strange here. It seems like nothing has worked. The bottom line is that this—what you’ve been doing—isn’t working. Not in terms of reducing your anxiety: it’s still there. And not in terms of your life working: you still aren’t around people, still aren’t working.
Explanation: The therapist directly addresses the issue of workability, both in terms of gaining control over unwanted internal experiences and also in terms of larger life goals. This is a fairly direct response. Some clients won’t react well to such directness, but some will. If you choose to use this kind of approach, it’s important to do so in alignment with the ACT therapeutic stance, which includes compassion—recognizing that sometimes compassion means helping people see when their behavior is leading to more suffering over the long term.
Therapist: So you say you do something and it works for a little while. Let’s follow this out a bit. What happens next?
Client: Things go okay for a period of time, but the anxiety comes back and I’m right back in it.
Therapist: And then what happens?
Client: The same thing… It just starts all over again.
Therapist: And when it starts all over again, what does it seem like the thing to do is?
Client: Try harder.
Explanation: As in the previous model response, the therapist is directly addressing the issue of workability, but this time pointing to the repetition of failed strategies. From here, the therapist might move to why we humans keep trying to control our internal experience even though that doesn’t work. This could be followed by a discussion about why we keep using control: that it works outside the skin, that we’ve been taught it should work, and so on. This will help clients understand that they aren’t to blame for continuing to engage in an ineffective approach.
Competency 4
Therapist: Feeling silly is tied to this, too…another thing to get over. It seems that there’s a lot of work to be done. First you have to get over feeling anger, and then the feeling that you shouldn’t have the anger, and then the feeling of embarrassment and the thought that you’re stupid about the anger…and then silly. This is a big struggle, and also it seems to be growing… It’s as if you’re in a tug-of-war with your emotions. If they win, you lose. And you keep trying to win, but it seems that no matter how hard you pull, your emotions don’t ever lose… I wonder if there’s a different way to play this game? Maybe this isn’t about winning the tug-of-war but about learning how to drop the rope.
Explanation: Here the therapist is working with the client to help her see that the problem is the struggle with internal content, not the content itself. The therapist should stay grounded in compassion for the client’s protracted struggle. These feelings of anger and embarrassment and thoughts of being stupid are natural reactions to being betrayed in a relationship. The difficulty isn’t that they occur, but the attachment to them and struggle against them. The therapist is directly encouraging the client to practice acceptance through the metaphor of dropping the rope. If the client is willing to feel these things as they are, then she can step out of the struggle and focus on her life direction instead. This isn’t a simple thing; it’s difficult to drop the rope because battling to make unwanted experiences go away feels like the thing to do. So when taking this approach, it’s important for the therapist to maintain compassion for the client and to communicate recognition of the difficulty of the struggle and how easy it is to engage in it.
Therapist: Well, let’s take a look at the anger for a moment. If I could reach over and peel the anger out of you and see what’s left behind, what do you think I’d discover?
Client: (Hesitates.) More anger.
Therapist: And if I could peel that away, too? I wonder if I might discover a very powerful feeling of hurt and betrayal… Is it possible that the anger is a way to escape the pain?
Client: Yes.
Therapist: What if all of this struggle you’ve been experiencing is about avoiding pain, but the only way to move forward is to turn toward the pain, rather than away from it?
Explanation: The therapist is addressing the problem of avoidance as part of the struggle, in this case by looking at the function of the client’s anger: avoidance of pain. The therapist is leading the client in the direction of willingness to experience pain as an alternative to the long-standing struggle to escape it. The goal is to help the client recognize and even welcome the pain (perhaps using the Annoying Neighbor metaphor to support this kind of welcoming), rather than staying focused on escaping it. If she’s willing to experience pain, she has functionally dropped the rope.
Competency 5
Therapist: Do you know what would happen if you went inside the anger and tried to see what’s there? Maybe it doesn’t need to go away for you to do something different with it.
Therapist: I can see why it doesn’t make sense to you. But maybe it depends on your goal. If your goal is to feel better, to not be angry anymore, then it seems trying harder to fix the anger would be a reasonable thing to do. It’s logical, right? However, if your goal is to find another relationship, then focusing on getting rid of anger may interfere with doing whatever there is to be done. There are other things people do to find relationships: go to parties, make phone calls, have friends introduce them to someone—things like that. It seems you’re trading away finding a relationship for getting rid of anger.
Explanation: This response points to how the endeavor to control internal events often comes at the expense of vitality. The client believes that when she doesn’t feel angry anymore, she’ll be able to find someone. In the meantime, years of her life are slipping away. If she’s willing to feel the anger and hurt while also making choices that lead to vitality, she might not feel so stuck. It’s important to note that the therapist isn’t asking the client to be angry. Rather, the therapist is supporting moving forward and creating the opportunity to be in a relationship without insisting that a different feeling be there first.
Competency 6
Therapist: What do you think would happen if you stopped putting so much effort into making the anger go away? It seems like a lot of suffering accompanies this effort. Is there a potential for less suffering?
Explanation: By using this kind of questioning, the therapist is pointing out the difference between willingness and suffering. The effort alone has become burdensome and weighs on the client. Simply suggesting “no effort” opens the door to willingness and can potentially lead to a decrease in suffering.
Therapist: Does the difficulty of trying to make your anger go away make you angry? (The client nods and laughs.) I thought it might. A strange thing happens when we’re working to control certain emotions. If you really don’t want to be anxious, for example, then you feel anxious about getting anxious. Or if you really don’t want to feel stupid and silly, then you feel stupid and silly about feeling stupid and silly. Do you see what I’m talking about?
Client: Yes.
Therapist: And now you have anger about your anger. We could distinguish it by calling it “suffering anger,” as opposed to “natural anger.” “Natural anger” is the anger that shows up when you feel betrayed…and hurt is in there too. “Suffering anger,” on the other hand, is anger about the anger.
Explanation: As in the previous model response, the therapist is helping the client investigate the difference between willingness and suffering. Willingness to experience the initial and natural anger and hurt while also noticing thoughts of being duped is much different from having these experiences and then insisting on not having them while also being angry for having them. The insistence creates more pain. The therapist is setting the stage for willingness as an alternative.
Therapist: You say you can’t even begin to describe how hard it’s been. It’s as if getting rid of this anger is almost more challenging to deal with than the anger itself.
Competency 7
Therapist: If we work this out logically, it seems as though you’ll have to trust men again before you can have the relationship and life you’d like.
Client: Yeah.
Therapist: I sense a problem here. In my experience, trust doesn’t work that way. It doesn’t just show up. Trust is a process. In the meantime, while you’re waiting to be trusting, you find yourself alone. I’m wondering… When you’re sitting there feeling lonely, does your trust of men grow or get smaller?
Explanation: Here the therapist is pointing to the difficulty of trying to make a particular feeling show up as a way out of another experience. This too can be costly. If the client is waiting to feel trust, she could be waiting a long time. And as the therapist points out, sitting alone being angry doesn’t build trust in men; it builds mistrust. The cost of the client’s unwillingness to feel whatever is there to be felt when she goes out with men doesn’t allow the process of building trust to happen.
Therapist: If you were able to trust men, what would you hope would happen?
Client: (Speaks in a sarcastic tone.) Well, then I’d be able to at least have a shot at being in a decent relationship—if I could actually find a decent guy.
Therapist: So what you want is to get over this guy so you can have a decent relationship, right?
Client: Yeah.
Therapist: Can I ask you a question about that? (The client nods.) And I’d like you to check your experience as you answer it. Don’t just check your head; notice what your experience has to say. As you work hard to get over that breakup, are things working out the way you hoped they would? You know, as you’ve worked to get over it, have you been getting closer to having the kind of relationship that you want, or have you found yourself paradoxically moving further away from it?
Explanation: The therapist helps the client examine the paradox of control and its costs in terms of not engaging in values-based actions. The client is waiting, and in the meantime she’s putting what’s important to her on hold.
Competency 8
Therapist: I invite you to notice how your mind is pulling you into the future. It’s saying you need to feel and think something completely different—that something significant would have to happen. What if instead we stay here, in this moment? What if it were okay to feel what you feel and think what you think? Not “okay” meaning you like it, but “okay” meaning you’re present to it. What if there were no need for it to be different, not in this moment or any other moment in the future. Experiencing fear of loss or betrayal will show up when it shows up. We can’t predict the future. If this makes sense to you, the question really is this: What is present for you now, and are you willing to experience that more fully? If you let yourself contact these emotions, here and now, what is your experience?
Explanation: Willingness isn’t about the future; it’s about the present, and there are always feelings and thoughts to be experienced. Orienting the client to this notion and bringing her into the present helps her see one of the qualities of willingness experientially, not just through explanation.
Therapist: So, here it is. It feels like something significant would have to occur, like never being duped again. “Duped” would have to go.
Client: Yeah, I don’t want to feel stupid like that. I don’t ever want to be in that position again.
Therapist: Can you contact “duped”? What are the qualities of “duped”? It sounds like “stupid” is in there. What else is in there? What else is in “duped”?
Client: Well, I guess I feel a little shame and embarrassment, like I should have known better.
Therapist: So there’s betrayal—which is painful stuff—and what comes along with it is embarrassment and shame, and your mind is giving you “stupid” and “should have known better.”
Client: Yeah. I even feel it a bit as we talk about it.
Therapist: Ah, and as you feel that and think that, is it possible to carry that stuff with you willingly, and to head into a relationship or into the stuff that you do to get a relationship?
Client: I suppose I could, but I don’t want to.
Therapist: That’s understandable.
Client: I mean, I don’t want to have to feel that again.
Therapist: I hear you. And yet here you are feeling it a little even as we talk about it. You have a good sense of what these experiences feel like.
Client: I know them all too well.
Therapist: Will those be the things that keep you out of relationships? Or given that you know these experiences, could you feel them and think them and still do the stuff that gets you into relationships?
Client: You mean, like feel embarrassed and still go out with someone?
Therapist: Yeah, would you be willing? I’m not asking you to like it, but if it got you headed toward connection and a relationship, would you be willing to hold this stuff as you know it and take some kind of action?
Explanation: The client’s statement that something would have to change suggests experiential avoidance. The therapist makes a guess at what the client is avoiding by saying, “‘Duped’ would have to go.” The therapist then proceeds to bring the avoided emotional experience into the room and leads the client to explore it, make room for it, and experience it willingly. In addition, the therapist works to change the function of the word “duped”; if the client is willing to have “duped,” it is no longer in control of her behavior. Finally, the therapist is careful to differentiate willingness from wanting or liking and also ties willingness to valuing.
Therapist: What if possibility isn’t based on how you feel but is instead based on what you do?
Explanation: This response points to the central quality of willingness: that it entails actions taken by choice. Willingness is embodied by doing; it’s a stance taken toward emotions, thoughts, and sensations while engaging in values-based actions.
Competency 9
Therapist: So, one thing we could do is focus on the money, but that doesn’t seem as though it would be useful right now. If you’re interested in keeping this relationship, it seems we need to work on the things that would make that happen. You’re saying you can’t bring yourself to talk to your wife or look at her, as if the disappointment were holding you back.
Client: Yes.
Therapist: Is it possible to feel disappointed and actively choose to talk to and look at your wife?
Client: No, I don’t think that’s possible.
Therapist: If it were possible, would you choose it?
Client: Yes.
Therapist: So here’s the deal… Would you be willing to feel disappointed and talk to your wife if it meant you got to keep the marriage? (Pauses.) Have you ever thought something in your mind but done something different with your actions? For example, have you ever thought, “I don’t feel like getting out of bed today and going to work,” and then you did it anyway? This is a bit like that: you have the feeling of disappointment, and you talk to your wife.
Explanation: Multiple things are happening in this response. In addition to establishing willingness as a choice, the therapist addresses engaging in values-based action and could then continue to work with the client on taking action while accepting the disappointment. In other words, the disappointment need not be resolved before the client can begin to interact with his wife. And in a dynamic similar to that in other examples for this core competency, it’s likely the client’s disappointment will grow if he continues to choose not to interact with his wife. Using the metaphor of the Annoying Neighbor, described earlier in this chapter, could be helpful at this point. If used, this metaphor shouldn’t be delivered in a trivializing or lighthearted manner. A relationship is at stake, and any metaphor used should reflect the gravity of the situation.
Therapist: (Stands up and walks around.) I can’t stand up and walk around right now. There is no way for me to do this. I am incapable of walking at this moment. (Sits back down.) And I certainly don’t want to sit down. (Pauses.) See how that happened? I had the thought that I didn’t want to do something, and I did it. You have the thought that you can’t talk to your wife, and you could do it…if you choose to. I know it doesn’t seem as easy as what I just did, but I want to point out that this might be both easy and hard at the same time. It’s hard because your mind says it is, and it’s easy because it’s simply a chosen action. Probably lots of thoughts and feelings will come and go as you choose to talk to your wife. These things work like that—they come and go, yet they aren’t what chooses your behavior.
Explanation: The therapist’s small, experiential demonstration helps the client see that thoughts don’t control behavior. They’re associated, but not causal. The client can choose to take action with respect to his relationship: he can choose to look at his wife and talk to her while also experiencing disappointment and all the other emotions and thoughts that are likely to show up in such a situation. Some readers of the first edition of this book expressed concern that this kind of approach could lead clients to feel like the therapist was mocking them, and this is a possibility to watch out for. If something like this does result in an alliance rupture or misunderstanding, this can be a good context for learning about how attachment to a particular story or unwillingness to feel particular emotions can lead to relationship difficulties for the client (including with the therapist).
Competency 10
Therapist: I can feel myself wanting to move away from this topic because I can see how much pain it’s causing you. I can see the tears in your eyes. I almost want to change the subject and talk about the lost money, but I think it’s important to stay with the shame and disappointment. I wonder if we could take a moment and stay present to what’s in the room?
Explanation: Here the therapist demonstrates willingness by asking herself and the client to stay present to the different emotions in the room. It would be easy to shift the topic to the money or to a conversation about the client’s wife. It’s important, however, for both therapist and client to remain present to the emotion as the therapist models willingness.
Therapist: Lots of judgments and thoughts can show up around issues of money. I notice it in my own relationship. I wonder if there’s a way to see these stories for what they are—thoughts—and to not let them dictate how you and I interact with each other. Maybe we can recognize that judgment is a part of this process of talking about money and make space for these judgments as part of our relationship, instead of trying to make judgments something that have to be kept out of our relationship. I’m willing to have you experience these judgments and the things that triggers in me as part of caring about you. Are you willing to have your judgments and work to stay present with me?
Explanation: Here the therapist’s self-disclosure normalizes judgments about money, an approach that can foster acceptance. The therapist also demonstrates willingness to experience judgments and thoughts and still remain engaged in the session with the client. Making room for judgment without buying into it and moving forward in the session provides a model of willingness. In addition, the therapist frames the current, in-session situation in terms of acceptance of judgments in the context of the relationship itself. The idea is that judgments can be included in the relationship, rather than being a barrier that must be eliminated or removed before connection is possible.
Competency 11
Therapist: I wonder if starting small makes sense. Would you be willing to feel what you feel when you look at your wife and still look at her, even if for just a few moments, if it meant you got to have your connection with her back?
Explanation: Here, the therapist is linking a small display of willingness to the client’s values. She’s helping the client open up to the difficult emotions he experiences when looking at his wife—not just for the sake of feeling difficult emotions, but in the service of values-based living. The therapist is also using a graded approach by suggesting “a few moments” as a starting point.
Therapist: Let’s look at not knowing where to begin. Finding that initial place to reengage can be challenging. Your mind will say, “I’m too disappointed. I can’t.” But if you were to take your mind with you and not let it be in charge of your actions or your willingness, what might you choose to do as a small start?
Explanation: The therapist is using defusion to support willingness while also turning to the client for a suggestion about where to begin. Again, this is a graded approach because the clinician is asking for a small action the client might take to reengage with his wife. If the client were to offer something fairly major, like showing affection, the therapist would assess the likelihood of the client being able to do this and, if it seemed unfeasible, work with the client to dial the task back. For instance, with the therapist’s help, the client might decide to start by saying a few kind words.
Therapist: When you say it feels impossible to get out of this, it makes sense in terms of the way your mind might be working it out. But is it possible that your mind doesn’t have an accurate assessment of this situation? If it truly is impossible, where do we go?
Client: I see what you mean, but I just feel so stuck.
Therapist: Well, maybe the answer isn’t in figuring it all out now—knowing the outcome. Perhaps it can be done in a step-by-step fashion, bringing willingness to doing each action in a more planned way. This will present its own challenges. It will probably feel awkward and hard at times, but it would be a process of open engagement, not an all-or-none deal.
Explanation: Here, the therapist is working with the client to set up a more structured path he can follow to reengage with his wife. This helps create a sense that the client can get unstuck by choosing to be willing in the presence of a well-planned strategy while also addressing the process. There is no particular outcome that can be predicted, but ongoing engagement in the process is a way of engaging in values-based actions no matter what the outcome. The therapist also acknowledges the awkwardness than can show up when approaching an interpersonal relationship in a planned way. Ultimately, the therapist and client can work together to come up with a structured approach, such as starting with a few kind words, moving to eye contact, then to touch, and so on.