Chapter 25

Values Choice and Clarification

Tobias Lundgren, PhDAndreas Larsson, PhD

Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institute; Stockholm Health Care Services

Definitions and Background

Clients often come into therapy stuck in a difficult life situation with troublesome emotions, thoughts, memories, and physical pains. In their struggles, it is not uncommon for them to have lost contact with what gives life meaning and purpose. Cognitive and behavioral treatments have increasingly been willing to address this deficit by reorienting them toward their values choices.

Values and discussions of valued choices are a core part of acceptance and commitment therapy (Hayes, Strosahl, & Wilson, 1999, 2011), behavioral activation (see chapter 19), motivational interviewing (see chapter 27), and a wide variety of other evidence-based methods. Historically speaking, values work in psychotherapy was the province of humanistic psychotherapies. Viktor Frankl wrote extensively on the drive for meaning, drawing on his experience in a Nazi concentration camp during World War II, and applied these ideas in logotherapy (Frankl, 1984). Carl Rogers, another famous humanist, thought the pursuit of values to be essential in self-actualization and ultimately psychological health. Using a card-sorting task comparing a client’s self-perception to an ideal self before and after therapy, he developed data supporting his person-centered approach (Rogers, 1995). Rogers’s ideas were brought into evidence-based therapy by motivational interviewing, in particular (Miller & Rollnick, 2002).

Values in the cognitive behavioral literature have been defined in multiple ways (Dahl, Plumb, Stewart, & Lundgren, 2009; Hayes et al., 2011), but for the purposes of this chapter we will adopt the definition of “freely chosen, verbally constructed consequences of ongoing, dynamic, evolving patterns of activity, which establish predominant reinforcers for that activity that are intrinsic in engagement in the valued behavioral pattern itself” (Wilson & DuFrene, 2009, p. 64). It seems worthwhile to unpack this definition to see how it may guide us in working with values.

Values are freely chosen. “Freely chosen” means they are chosen in a context free from aversive control. As much as possible, a reduction in aversive control is almost a prerequisite for choosing values. People formulate and choose values that are theirs, and therapists need to be cautious about suggesting that their own values are preferable over client choices.

Values are verbally constructed consequences of ongoing, dynamic, evolving patterns of activity. Values are not just the direct consequences of action—they are constructed as important consequences through speaking and symbolic thought (see chapter 7). Values are part of the context of action systems and cannot be separated from action. They are not some kind of entity out there to be discovered or held onto.

Values establish predominant reinforcers for that activity that are intrinsic in engagement in the valued behavioral pattern itself. Values are about what is important and sought after. Values are an inseparable part of the behavior they reinforce, in the moment when the behavior occurs.

For example, imagine you are at home with your child and there is a lot of work to get through that you left undone at the office. Now in this moment, seeing that your child needs your attention, you put down your laptop and choose to fully engage in conversation and play with your child. If this moment of connection with the importance of active parenting makes it more likely that you will do the same the next time, we can say that being an active parent is a value of yours.

Values work can function in therapy as a motivator for change, as a metric for the effectiveness of actions, and as a guide in the development of new behavioral repertoires. Values work can be done at any point in the therapeutic process. Values interventions are used to help clients stop vicious, negative life cycles and get in contact with more effective behavior patterns.

Implementation

We will give an extended example of values work using the Bull’s-Eye Values Survey (BEVS). During the last decade, the BEVS has also been developed and investigated as an outcome and mediator measure in research. Changes in valued living as measured by the BEVS are associated with higher quality of life and lower depression, anxiety, and stress (Lundgren, Luoma, Dahl, Strosahl, & Melin, 2012). BEVS scores mediate changes in behavioral health (Lundgren, Dahl, & Hayes, 2008) and mental health areas (Hayes, Orsillo, & Roemer, 2010). The aim of the BEVS is to (1) help clients clarify their values, (2) measure how well they are living in accordance with their values, (3) operationalize obstacles for valued living and measure their perceived effect, and (4) create a bold but reasonable valued action plan that challenges expressed obstacles. In the following section, a client-therapist interaction will demonstrate all four parts of the BEVS.

This clinical example is based on the case of Erik, a forty-year-old carpenter. Erik suffers from depression and anxiety symptoms and has been rehabilitating a back injury that has left him with chronic pain. He has two children and a wife who works in the children’s day-care system.

When Erik came into the office he looked tired. He answered questions but was not particularly responsive with eye contact or in his body language. After two sessions creating rapport and collecting information, the therapist decided to help Erik clarify his deeply held values so as to increase the likelihood of new action paths in his life.

Therapist: Erik, I would like to understand what you have lost during your fight with depression, anxiety, and pain.

Erik: I have lost everything, my life…

Therapist: (Pauses a couple of moments.) Tell me more about the life you have lost…

Erik: I have lost contact with my kids, my wife, lost my friends, my love for sports…lost taking care of myself. It awakens memories of how things were before. (Looking at the therapist.) I remember playing sports with my kids, talking about life with my wife, and just hanging out with friends playing basketball and laughing. I really miss that.

Therapist: Okay, it seems to me that there is something really important here. Is it okay for you to look more closely at this?

Erik: Sure, if it can help me get better, I am open to anything.

Erik has lost a lot in his struggle with depression and anxiety. In the next section, we’ll illustrate how the BEVS can be used to explore that issue: clarifying values and investigating values consistency.

The bull’s-eye dartboard, used in the BEVS, is a visual representation of the four areas of living that are important in people’s lives: work/education, leisure, relationships, and personal growth/health. It is okay to use these areas as they are defined here, and to go through all of them with a client; it’s also fine to not have the domains predefined, and to instead define them with your client. The following descriptions of these four areas should clarify what we mean by “values” and should stimulate thinking around values:

1. Work/education refers to career aims, values about improving education and knowledge, and generally feeling of use to those close to you or in your community (i.e., volunteering, overseeing your household, etc.).
2. Leisure refers to how you play in life, how you enjoy yourself, hobbies, or other activities that you spend free time doing (e.g., gardening, sewing, coaching a children’s soccer team, fishing, playing sports).
3. Relationships refers to intimacy in life—relationships with children, family of origin, friends, and social contacts in the community.
4. Personal growth/health refers to your spiritual life, either in organized religion or personal expressions of spirituality; exercise; nutrition; and addressing health risk factors such as drinking, drug use, smoking, and weight.

Clarify Your Values

Start your work with the BEVS by asking the client to describe her values within each of the four values areas. The therapist invites the client to think about each area in terms of her dreams, as if she had the possibility to get her wishes completely fulfilled. What are the qualities that she would like to get out of each area, and what are her expectations from these areas of life? Her values should reflect how she would like to live life over time rather than a specific goal. For example, getting married might be a goal that reflects the value of being an affectionate, honest, and loving partner. To accompany her son to a baseball game might be a goal; to be an involved and interested parent might be the value.

Suggestions to Deepen Values Work

Expand on experiences. Was there a time in the past when your client had a life worth living? Ask your client to close her eyes, take a couple of breaths, and connect with situations in the past, when life was good and really worth living. Help her see herself in one of those situations. Deepen the experience by asking for emotions and images. How was that life, and how was your client acting back then? What can she see? Are there other people involved in those memories? How did she act, and how were the interactions for her? Try to get the client to really connect with the past experience of having a life worth living.

Take your time. If your client is open, willing, and able to connect with past experiences of having a life with purpose and meaning, don’t rush the work. Help your client to stay inside the values context. You want to help your client to be able to do this outside the therapy room, and you start the process in therapy. Explore that value, feel it, and stimulate further exploration of it.

You find values in suffering. Values are often found inside suffering. For example, a client would rarely be afraid of other people or of being rejected if relationships were not important. This means that values themselves, and values talk, may also evoke suffering. Take it slow, and acknowledge that suffering and values often go hand in hand.

Go beyond goals. Often clients can start describing goals instead of values. Try to help clients go beyond the goals. If a client states that he would like to start working out three times a week, ask why doing so is important to him. Why is taking care of the body by working out important? How does he want to approach the workouts? What are the important qualities in your client’s actions that will make working out a good experience? How are they related to a meaningful life?

Balance pushing and choosing. Be aware that sometimes values work is not the best way to move forward. If the suffering is too overwhelming, questions about values may fall flat. If you have pushed for values and doing so has not worked, be ready to change your approach. You may need to do other therapeutic interventions first and come back to values later. However, sometimes it can be effective to push on. The art of psychotherapy is to be present with your client and to continuously keep your functional analysis in mind. You need to figure out how you need to act in order to be of service to your client.

In the following conversation, Erik and his therapist deepened their values work.

Therapist: In this exercise, I want us to look more closely at your values. Is there a life domain that you would like to start with?

Erik: The most important thing for me is the contact with my kids. My wife too, of course, but I would say kids first.

Therapist: Okay, let’s start there then. Can you contact an experience, a moment in the past when you were how you want to be with your kids? When you had the contact and relationship you want with them? Take your time.

Erik: Yeah. (Smiles.) I remember when we were playing soccer in the garden. We had fun and laughed together; I didn’t think of possible pain, or ruminate. We were just there together, hanging out. Thinking of that also makes me a bit sad. I miss that contact.

Therapist: Mixed feelings here, both joy and sadness. What does that contact mean to you?

Erik: It meant and means the world to me! I can really sense our relationship, the connection, the happiness in my body and my love for them.

Therapist: If we could strive to get that relationship back into your life, would you be willing to work for that?

Erik: Absolutely, I would do anything!

Therapist: Take a couple of moments and write down a brief description of the relationship you would like to have with your kids. What’s in that experience you contacted? How were you acting with them at that time?

Erik then wrote this values statement in relation to his kids:

I want to be a present dad. I want to play with my kids, see them, and be there for them not only when we have fun but also when they have a hard time. I want to be active, listen, and show them that I care for them. Even if I physically can’t be the person I used to be, I love my kids and need and want to find a way to be with them. I want them to know that I love them very much.

Erik and the therapist always could have reinvestigated values as therapy proceeded, but at that point in therapy the therapist used Erik’s statement for the BEVS work. They had established a value to guide therapy and to help motivate Erik to break vicious action patterns and establish new ones. For the purposes of this chapter, we will not go through all the areas of the BEVS. Instead, we will use Erik’s relationship with his kids as an example of how values clarification work can be done and explain the different functions of the values work.

Erik and his therapist then investigated how Erik’s actions coincided with his value.

Therapist: Now, look at this dartboard we developed. We’ll use the relationship area. The middle of the dartboard, the bull’s-eye, represents being a present and active dad: the dad you want to be with and for your kids. Now, mark an X on the dartboard that best represents how well you have acted in line with those values during the last two weeks. An X in the bull’s-eye means that you have been living completely in line with how you want to be as a dad. An X far from the bull’s-eye means that you have not been living as you want in relation to your kids.

Figure 1. Erik placed his X far from the bull’s-eye.

Erik and his therapist then went on to talk about the discrepancy between how Erik wanted to be with his kids and how he actually had acted during the previous two weeks. His actions did not coincide with his value, and this discrepancy became a motivator for change.

Therapist: In our previous talks, you told me that your actions lately have been about avoiding shame and guilt around not being a good enough father. What does looking at the dartboard tell you?

Erik: It tells me that I am far from being the dad I want… It makes me sad on the one hand but also eager. I want something else. I want to be in the bull’s-eye. I have not thought about the dad I want to be or those moments we have had together in a long time. I have been so filled up by anxiety and thoughts about not being good enough. When I think of the dad I am today, it is far from the one I want to be. I want to make a change.

Therapist: That sounds really important and also painful—to see what you are missing.

Seeing the discrepancy between Erik’s values and his actions created a space that he was eager to fill with meaning and valued actions. Hopefully this work can establish a verbal operant to motivate choices in line with his values.

The therapist and Erik then examined obstacles for change.

Therapist: Erik, I want you again to contact the obstacles that pop up for you when thinking about being the dad you want to be. Take your time and really connect with that.

Erik: (Tearing up.) I feel ashamed that I haven’t done better… I feel tired…hopelessness…fear that if I start to be active it will increase my pain, and also that they will reject me.

Therapist: Feelings and thoughts, intertwined around fear of not being the dad you had imagined you would be… Can I ask you a question? When these thoughts and feelings emerge in situations around your kids, how often are they controlling what you do? (The therapist gives Erik a sheet of paper with a horizontal line of numbers, with the 1 representing little control of feelings, and 7 representing complete control. The therapist instructs him to circle the number that best represents how often his feelings and thoughts prevent him from being the dad he wants to be.)

In situations with his children, and when Erik thought about his role as a dad, obstacles emerged and Erik began to avoid rather than to act in line with his values. Avoidance reduces fear and pain in the short term, but in the long run it may reduce life quality. His actions narrowed his life path. It is important to note that as therapists we need to work with these obstacles using all our knowledge of cognitive and behavioral treatments. Values work supplements and supports this work.

The final step in the BEVS is to create a valued action plan. The therapist asked Erik to formulate actions he could take in daily life that would tell him that he was zeroing in on the bull’s-eye in the area of being the dad he wanted to be. These actions could be small steps toward a particular goal, or they could just be actions that reflect how he wanted to be as a dad. Usually, taking a valued step includes being willing to encounter the obstacle or obstacles the client identified earlier, and to take the action anyway. The therapist asked Erik to identify at least one value-based action he was willing to take in the area of being the dad he wanted to be.

Therapist: Erik, what would be a step that you would be willing to take that would move you in the direction of being the present, active dad you want to be even in the face of emotional difficulties and obstructing thoughts? It doesn’t need to be a big step, but most often the step means that you will challenge your fears a little.

Erik: One thing that I have thought about is to ask my eldest son to go to a hockey game. We did that before, but now I have been afraid that I would be tired and need to cancel, so I haven’t even asked. Both Ludwig, my son, and I really liked going to games, and I am pretty sure that he would like to do that again.

Therapist: Great. I can see that means something for you. So, when is there a game you could go to? And when can you ask him?

Erik: There is a game at home this weekend, and I could ask him tonight because we probably need to get tickets right away.

Therapist: Okay, so you will ask him tonight and get tickets together. How is it for you to plan reconnecting with your son?

Erik: It feels great doing that, and also a bit scary. What if I get anxious, and what if he says no?

Therapist: Your fears will probably pop up now and then in this process. Can you let them come along when you reconnect with Ludwig?

Erik: Sure. For my son, absolutely!

Summary of Working with the BEVS

Erik was occupied with troublesome thoughts and emotions, and the BEVS work helped him to both clarify his values and what his actions had led to in the short and the long runs. Prior to Erik’s contact with the therapist, his values had been put on hold. Through their work together, the therapist and Erik brought his values forth into attention again, stimulating new behaviors. This was not the end of the therapeutic journey for Erik—values work usually sets the stage for interventions designed to handle the obstacles that emerge once values are put into action. Those methods are covered elsewhere in this volume.

Clinical Pitfalls

Words are tricky. Be aware of how your clients talk about their values. Statements like “I really need to be a better dad” or “I must do this or that” can indicate that values are entangled with avoidance and suffering.

Outcomes can dominate over process. Values work is not about forcing behavioral outcomes. Often therapists suggest goals or actions, and when an action occurs, they assume therapy has been successful. It is important to focus on how valued actions occur, because when they truly are valued, they tend to become a natural part of the client’s behavioral repertoire.

Just do it! Done incorrectly, values work can sound like “Ignore your pain and move forward no matter what.” That kind of stoic, teeth-clenched change is not what we want as therapists. We want clients to develop new skills, and by doing so live a meaningful and psychologically healthy life.

Goals vs. values. This is a place where therapists often get stuck, especially beginner therapists. If a client answers values questions with concrete goals, try to move up in the hierarchy to qualities of being and doing.

Morals vs. values. It is easy to get stuck in what is right and wrong when it comes to values. With values work we want to help our clients to formulate statements that function to motivate actions in line with living a personally good life. If your client states values that you are not willing to support, you should consider referring the client to another therapist. This doesn’t happen often, but if it does try to see what’s best for your client.

Clients are not stating values as I know values! We are looking to develop values statements, closely connected to client experiences, that motivate action in helpful directions. The topography of words is not interesting in and of itself. If you find yourself wrestling your client into stating the “right” words, pause, reflect, and ask the client to tell you more about what he cares about, what he misses in life, and what matters to him. Don’t push clients to formulate certain values words. Doing so will not be as effective as trying to understand and take the perspective of your client. Be curious and learn to understand the words your client is using to express his values.

Client barriers becoming therapy barriers. If you start to think This person needs X before she can move in a valued direction, you are likely encountering a barrier, oftentimes a barrier the client is also experiencing. Often this means you are stuck in thinking that the client’s expressions of obstacles are literal truths. They are not; they are expressions of suffering and inflexibility in that moment that you need to treat functionally. Try to work with the barrier using your normal therapeutic interventions, and investigate to see if you can find a way to help your client, allowing values and expressed barriers to coexist.

Fused values becoming new ways to punish oneself. If values statements become rigid and aversive, they are no longer values as we mean them. Particularly for people who are highly prone to self-shame or have a performance-based self-esteem, values can become a way to punish themselves. Often that itself becomes a barrier to moving in valued directions.

Applications

Values work can be an important part of any treatment. Even if not explicitly addressed, therapists should generally include some values work in their analysis of client behavior and its functions. Values are often useful when setting more traditional treatment goals. Here are some common clinical examples, broken down by problem areas.

Work-site stress. It’s difficult to overestimate the pressure that a well-crafted organization can place on an individual. This does not mean organizations are evil, just that when building an organization, certain functional properties are put in place to make people productive. This may lead some people to create rules basing their self-worth on productivity. If, for one reason or another, they produce less, this may impact their sense of self-worth.

Eating disorders. Eating disorders, bulimia, and anorexia nervosa are characterized by individuals trying to control internal experiences through food intake, most often in order to fulfill an idealized appearance. This is virtually an inverse of values. Because of the heavy dominance of aversive control, and how long the disorders have been present with people—meaning they have a lot of practice being aversively controlled—eating-disorders work often requires building a values repertoire.

Behavior medicine. In behavior medicine, values work can be especially important with chronic conditions, such as pain, diabetes, or epilepsy. Values are often put on hold when dealing with medical conditions. It is important to bring values back into an individual’s context to help the person find motivation for growth and change, even if the medical condition persists.

Addiction. In addiction work, it is common for past failures in valued domains (e.g., parenting) due to an addiction to dominate over engaging in the opportunities that arise in the moment (e.g., taking care of your child who is in front of you now). The importance of valued actions is especially clear during relapses. When people struggling to step out of addiction veer off a valued path, it is common to think I’ve broken the rule, so I might as well do a good job of it! By returning to the values conversation, it becomes possible for the person to see that the real choice is between a pattern of quit/relapse/quit and quit/relapse/fail. If the values behind abstaining, sobriety, or moderation have remained in place, that choice is clearer (Wilson, Schnetzer, Flynn, & Kurtz, 2012).

Depression. Lack of access to values-congruent reinforcement seems to be a key ingredient to maintaining depression. Values work is used to link behavior change to immediately reinforcing properties. It appears that doing more things that are meaningful is helpful in depression, and it is best for the clients to do these meaningful things not because they want to get out of the depression, but because these things matter deeply to them and move them in valued directions that lead to a more healthy, fulfilling, and meaningful life.

Anxiety problems. For anxiety, values and exposure work can go hand in hand. Values work lessens aversive control. If, as a therapist, you perform exposure based on values rather than symptom reduction, you are not just supporting nonavoidant behavior, you may be helping to reduce aversive control more globally, building out the “freely chosen” part of the definition of values given earlier.

Summary

Values work can empower most forms of evidence-based therapy by linking behavior change to meaning and purpose. Choosing and clarifying values appears to be a key process with wide applicability across problem types and treatment methods.

References

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Frankl, V. E. (1984). Man’s search for meaning: An introduction to logotherapy (Rev. and updated). New York: Pocket Books.

Hayes, S. A., Orsillo, S. M., & Roemer, L. (2010). Changes in proposed mechanisms of action during an acceptance-based behavior therapy for generalized anxiety disorder. Behaviour Research and Therapy, 48(3), 238–245.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York: Guilford Press.

Lundgren, T., Dahl, J., & Hayes, S. C. (2008). Evaluation of mediators of change in the treatment of epilepsy with acceptance and commitment therapy. Journal of Behavioral Medicine, 31(3), 225–235.

Lundgren, T., Luoma, J. B., Dahl, J., Strosahl, K., Melin, L. (2012). The Bull’s-Eye Values Survey: A psychometric evaluation. Cognitive and Behavioral Practice, 19(4), 518–526.

Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Helping people change. New York: Guilford Press.

Rogers, C. R. (1995). On becoming a person: A therapist’s view of psychotherapy. New York: Houghton Mifflin.

Wilson, K. G., & DuFrene, T. (2009). Mindfulness for two: An acceptance and commitment therapy approach to mindfulness in psychotherapy. Oakland, CA: New Harbinger Publications.

Wilson, K. G., Schnetzer, L. W., Flynn, M. K., & Kurtz, S. (2012). Acceptance and commitment therapy for addiction. In S. C. Hayes & M. E. Levin (Eds.), Mindfulness and acceptance for addictive behaviors: Applying contextual CBT to substance abuse and behavioral addictions (pp. 27–68). Oakland, CA: New Harbinger Publications.