In chapter 5, we covered how to help clients clarify their values, identify values-based action, and understand the benefits of enacting values-based actions, or VBAs, in all areas of their lives. In this chapter we examine how to help clients choose VBA when they get triggered, in the moment of choice. Through the Monsters on the Bus exercise and an imaginal exposure exercise, clients will combine the values clarification and motivation developed by completing the Values Domain Worksheet and the Benefits of Values-Based Action Worksheet with rehearsal of the VBA.
EET Skill Objective:Observe + Accept + Choose values-based action
The “monsters on the bus” metaphor is used in acceptance and commitment therapy (Hayes et al., 1999). It is a powerful experiential exercise to help clients practice tolerating distressing internal events and choosing to act on their values in triggering situations. In EET, we’ve modified the exercise to specifically include tolerance of distressing emotional experiences manifested in thoughts, feelings, sensations, and urges. By practicing observing and accepting emotional experience, and choosing VBA in the moment of choice, clients learn how to powerfully create what they want for themselves and their lives.
Your clients have already been practicing mindful acceptance, emotion surfing, and identifying the moment of choice. And they now understand the concept of choosing a values-based action in a triggering situation. The next step is for them to practice in session through imaginal exposure, as well as out of session, in vivo. When clients are willing to do this, they will learn that they can take the pain or distress with them on the path of VBA, instead of choosing to avoid painful emotions (emotion avoidance) or to act on their emotions (emotion-driven behaviors).
Facilitating the willingness to tolerate distress in the service of values is the key to choosing VBA. Clients must be motivated enough to allow for the distressing experience and still be able to choose to use a VBA instead of choosing experiential avoidance. This level of motivation and distress tolerance requires developing a clear understanding of why it’s better for them to stay on the path to values-based action than to veer onto the path of experiential avoidance.
Following is a step-by-step guide to setting up the Monsters on the Bus exercise and a therapist-client dialogue example of leading a client through the exercise. It may be helpful to use both the Values Domains Worksheet and the Benefits of Values-Based Action Worksheet as a reference with your clients.
Prep your clients for this exercise during session using the following steps:
The following script provides an example of how to approach the next part of this exercise with your clients.
Therapist: Okay. We’ve identified your values-based action, which is to sign up for online dating [points to other end of office]. This VBA is in the service of which of your values?
Client: Connection.
Therapist: And the VBA of signing up for online dating represents one way you can move toward connection?
Client: Yes.
Therapist: Okay. [Stands next to client] So here you are driving your bus along the road, which represents your life and all that goes with it. You’re driving toward your VBA, connection. Let’s go… [Motions to client to pretend to be driving while moving forward.]
Client: [Puts his hands on an imaginary wheel and steps forward with therapist.]
Therapist: [Steps forward to pick up the first “monster” on the sheet of paper and turns to stand in front of client driving the bus] Let’s face this first monster. [Reads] “No one is going to want to go out with me.”
Client: Yeah. That’s probably true [laughs mirthlessly].
Therapist: So it feels true that no one will want to go out with you. Can we stay with this for a moment?
Client: Sure.
Therapist: Great. Can you say more? What’s the feeing that goes with that thought?
Client: Um…probably fear of being rejected.
Therapist: Okay. So you worry if you sign up for online dating you’ll end up getting rejected—that no one will want to go out with you.
Client: Yeah.
Therapist: Okay. And when you feel afraid that no one wants to go out with you, where do you feel that in your body?
Client: In my gut. Kind of like a knot.
Therapist: Okay, so you’re afraid, and you have a knot in your stomach.
Client: Yeah. And I get that every time I sit down at my computer and think about signing up.
Therapist: Okay. And what is the urge that goes with this thought, sensation, and feeling?
Client: Just don’t do it! I want to avoid it.
Therapist: Okay. So when you are having this thought that no one is going to want to go out with you, and the knot in your stomach, and fear, you just want to avoid?
Client: Absolutely.
Therapist: So now that we’re here, can you locate your moment of choice?
Client: I see it…but I still want to avoid.
Therapist: Okay… Shall we try veering off the VBA path?
Client: Sure.
Therapist: [Comes back next to client and guides him off to the side of the office, away from the VBA path] So now we’re moving toward the path to experiential avoidance.
Client: Uh, okay. Hmm.
Therapist: So what’s it like hanging out over here?
Client: Well… I’m not so afraid anymore.
Therapist: Okay, so you’re not feeling the fear so much. What else?
Client: And the knot is better…
Therapist: Okay… So there’s less tension in your stomach?
Client: Yeah.
Therapist: Any thoughts coming up?
Client: Well, actually the thought that I’ll never find a partner is back…
Therapist: I see. And what’s the feeling that goes with that?
Client: Fear, actually.
Therapist: So now the fear is from not taking steps to try to find a partner?
Client: Exactly. And now the knot in my stomach is coming back.
Therapist: Sounds like a different monster over here? The fear that you’ll never find a partner, and the sensation is back?
Client: Seems that way.
Therapist: So, how’s the path to experiential avoidance working for you?
Client: It’s not. I’m still miserable.
Therapist: Shall we head back to the VBA path?
Client: Yeah, sure. At least over there I’m trying to do something good for myself.
Therapist: [Guides client back to start of VBA path] So where were we… ? We were hanging out with this monster called “No one is going to want to go out with me.” [Steps back in front of the client.]
Client: Yeah. That’s still probably true.
Therapist: Okay. So how do we move toward your VBA with that thought in your way?
Client: Run it over?
Therapist: [Chuckles] Good idea. But, unfortunately, in this game, like real life, we can’t kill the monsters.
Client: [Chuckles] Okay… So how do I move forward?
Therapist: Well, remember you’re driving a bus. So if you can’t run them over, and you can’t go around them or avoid them, what does that leave you with?
Client: Hmm… Take them with me?
Therapist: Exactly! You can let them on your bus.
Client: All right then. [Pretends to open the lever to the bus door.]
Therapist: [Picks up the sheet of paper with “No one will want to go out with me” on it and rejoins the client, standing next to him] Shall we move forward?
Client: Sure…
Therapist: What’s the next monster? [Picks up the next piece of paper, stands in front of the client, and reads] “I need to make more money before anyone will want to be with me.”
Client: Well that’s probably true.
Therapist: That feels really true, huh?
Client: [Nods.]
Therapist: Okay, let’s stay with that. What’s the sensation that goes with that thought?
Client: My chest feels a little tight. And I’m getting warm all over my neck and chest.
Therapist: And what’s the feeling that goes with the thought that you need to make more money for someone to want to be with you, and the tightness in your chest, and the warmth in you neck and chest?
Client: Hmm… I feel embarrassed about what I earn at my job. I guess the feeling is shame.
Therapist: You think it’s shame?
Client: Yeah, it’s shame.
Therapist: Okay. And what’s the urge that goes with this emotion?
Client: Well, just don’t put myself out there. You know…avoid.
Therapist: Okay, so here we are at your moment of choice again. Shall we veer off the VBA path and onto the path of experiential avoidance?
Client: No way! I’ve been over there and it’s not any better [looks dejected].
Therapist: Are you sure? It might relieve the distress, even for just a little while… You wouldn’t be fighting against this particular emotion…
Client: Yeah, I might feel less shame, but then the fear of being alone will kick back in.
Therapist: Okay. So what are you going to choose?
Client: Let the shame monster on the bus!
Therapist: Are you sure? You’ll have to keep driving with these emotions, and with all their thoughts, sensations, feelings, and urges…
Client: Yeah, I’m sure. They’re with me anyway, so I might as well try online dating.
Therapist: Okay, let’s keep going. [Comes back next to the client and moves forward to the next “monster,” and turns to face the client] What do we have here? [Reads] It’s the thought “If anyone really gets to know me, they won’t like me.”
Client: Ooh—that’s a good one. [Pauses] Yeah, I gotta be honest, I really do believe that one.
Therapist: You feel it’s true that if anyone gets to know you, they won’t like you?
Client: Yeah. My heart has started racing and my palms just got sweaty.
Therapist: Okay… And what’s the feeling that goes with those sensations?
Client: Panic.
Therapist: Okay. So you feel panic and your heart is racing and your palms are sweating when you have the thought “No one who really gets to know me will like me”?
Client: Yes. It’s pretty strong.
Therapist: This is a big one for you?
Client: Yeah. It’s a big risk, letting someone know me.
Therapist: Right. There’s always the possibility you won’t be a match?
Client: Yeah.
Therapist: So what is the urge that goes with this emotion?
Client: Well, to avoid, of course.
Therapist: Okay. So would you be willing to take that emotion with you toward your VBA?
Client: In this game or in real life [chuckles]?
Therapist: Both.
Client: Well, I know going off on the path to experiential avoidance isn’t going to feel good. But it might feel better than risking letting someone get to know me. But… I really want a relationship.
Therapist: It sounds like you do. And so far you’ve been willing to take these other monsters with you for the chance of finding connection.
Client: Yeah. I think I have to let this one on the bus too.
Therapist: You’re sure?
Client: Yes. I’m ready to try something new. I’m tired of being alone.
Therapist: Okay. Let’s bring this big monster on the bus. [Stands next to client and directs him to the VBA, picks it up, and hands it to him] Congratulations!
Client Thanks. Now I just have to do it for real.
Therapist: Yes. Can you commit to signing up for online dating before our next session?
Client: I will.
Therapist: Great. And if it gets hard, you’ll remember what it was like on the path to experiential avoidance.
Client: Yeah. It’s even more depressing over there.
After the Monsters on the Bus exercise is complete, you’ll want to consolidate what clients learned by asking about their experience, specifically: what they predicted would be hard, and what it was like allowing (observing and accepting) the distressing emotion; their experience of moving toward experiential avoidance; and their experience of moving toward the VBA. Be sure to ask them if they can commit to using their VBA in an in vivo situation. You’ll also want to emphasize that VBA doesn’t involve changing their emotional experience. They just become willing to tolerate it and can then “take it with them.”
If clients weren’t able to commit to moving forward during the Monsters on the Bus exercise, and instead chose to stay on the path to experiential avoidance, you still have several options. First, you could highlight that the costs of taking the path of VBA seem to outweigh the costs of taking the path to experiential avoidance; then reassess the clients’ rating of importance for this value. Second, you can choose a different VBA for which the clients are more motivated and willing to tolerate distress. Third, you can use imaginal exposure (discussed in the following section) as a way to increase their distress tolerance and willingness to allow the suffering while moving toward their VBA.
Now it’s time to practice choosing VBA using imaginal exposure to increase willingness to tolerate distress and to enhance learning, retention, and recall. Just as in previous sessions, imaginal exposure begins by using the O+A+C (observe + accept + choose) model. Once clients have practiced O+A+C and located their moment of choice, they will visualize choosing their values-based action, rating their SUDS level just before and after.
Imaginal exposure with rehearsal of the VBA helps clients more easily access the willingness to do a new behavior in future in vivo situations. From a neuroscience perspective, the rehearsal visualization makes new neural connections, allowing them to more easily fire together again in similar future situations.
Following is a step-by-step practice guide and a therapist-client dialogue example of conducting imaginal exposure with VBA.
Prep your clients to work with imaginal exposure during session using the following steps:
While clients are still visualizing the triggering event, have them observe any action urges that arise. Is there a desire to be verbally aggressive, to withdraw, to stonewall, to be defensive? Ask the clients to describe such urges, and get them to notice that the urges don’t have to become action. This is the moment of choice, and it’s important for the clients to stay with it for several minutes: observing the emotional pain, accepting and allowing the pain to be there without avoidance, and choosing not to act on emotion-driven urges.
Step 1: Selecting a distressing situation.
Therapist: It sounds like you had a difficult incident with one of your children. Tell me what happened.
Client: My youngest child refused to clean up his room. When I asked, he threw himself on the bed screaming. I shouted that he should get up and do what I asked, and then I dragged him off the bed. He fought me, and I pinned him to the ground and screamed at him to respect me and do what I ask when I ask it.
Step 2: Identifying the value and the VBA.
Therapist: Can you identify a key value you hold for your relationship with your son?
Client: I think it would be caring.
Therapist: Great. And what would be a values-based action to move you in the direction of caring in this situation?
Client: I want to let him know that I get that he’s unhappy. I’d like to interrupt his playtime in a calm way.
Therapist: Okay, great. How would you do that? Can you imagine a way to slow the situation down so it doesn’t escalate?
Client: I could give him a few minutes to think about the consequences of not stopping and cleaning his room.
Therapist: Great idea. So how long will you give him?
Client: I guess I could give him five minutes.
Step 3: Visualizing enacting the VBA.
Therapist: Okay, great. Let’s take a few moments and visualize the situation… Imagine you go into his room and see him playing, and you ask him in a calm voice to clean up his room. When he protests, you tell him he has five minutes to think about it, or else there will be a consequence.
Client: Got it.
Therapist: So now take a moment and close your eyes, and talk me through it in your own words.
Client: Okay. I’m going into the room. I see him playing and I say—calmly—“Honey, I need you to stop what you’re doing and clean up your room.” And then he starts to pout and says, “I don’t want to.” So I calmly say, “I know it’s hard for you to stop playing.” I see he is not stopping, so I say, “I’ll give you five minutes to make up your mind, and when I come back I would like you to stop and clean your room, or there will be a consequence.” And then I walk away.
Therapist: Great. Now let’s do that one more time. Talk me through it.
Client: Okay. I come into his room and see him playing there. I calmly ask him to stop playing and clean up his room. He starts pouting and says he doesn’t want to. I don’t react, but I calmly say that I understand he doesn’t want to stop playing, and that I’ll give him five minutes to make up his mind, and that when I come back I need him to be cleaning or there will be a consequence.
Therapist: Okay. Good work.
Step 4: O+A+C + VBA.
Therapist: Now let’s move into the exposure. I’ll talk you through it. Start by imagining the scene, noticing anything you see, hear, or sense. You’ve asked him to clean his room and he protests. What are you noticing right now about your urge to yell?
Client: It’s strong. I want to take control.
Therapist: Stay with that. Notice the urge, but be aware you have a choice. You could yell or not yell.
Client: Okay, I’m really pissed, though. I really can’t stand it when he acts that way.
Therapist: Right. Notice the pain, how helpless and disrespected you feel. Can you describe that?
Client: Yeah. Being ignored—I feel like I’m nothing, like I don’t matter.
Therapist: Okay, keep watching that feeling and try to just allow it. Make room for it without controlling or pushing it away. Can you do that?
Client: I’m just watching it.
Therapist: And what about that urge to yell? Can you see your moment of choice right now? That you could actually have this pain without yelling?
Client: Yes. I’m watching myself feeling the urge. I see the choice.
Step 5: Imaginal exposure with VBA.
Therapist: Okay, good. What is your SUDS rating in this moment?
Client: A 6, maybe.
Therapist: Okay. Now, can you see yourself calmly and gently telling your son that you understand how hard it is to stop playing? [Pauses] And now can you explain there will be a consequence if you have to pick up his toys? Imagine saying that with a calm, caring voice.
Client: Yes, I can see that.
Therapist: Now, notice that he isn’t stopping, and hear yourself giving him five minutes to decide.
Client: I’m still pissed off, but I can imagine doing that.
Therapist: Good, let’s go through the scene again, starting when he refuses to clean up and throws himself on the bed. Notice the pain and the urge to yell. Now see yourself going through each step of your intention. [The client repeats the sequence several times.] What is your SUDS rating now?
Client: A 3, maybe. I feel calmer.
Step 6: Consolidating what was learned.
Therapist: Let’s talk about the exposure. What was it like just being with your feelings and accepting them while observing your moment of choice?
Client: Well, I’m getting better at watching my feelings and not being so overwhelmed by them.
Therapist: Great. And what about adding the visualization of doing your VBA—imagining carrying out your intention to be caring with your boy?
Client: It’s weird, just making it up—something that didn’t really happen. But somehow I feel like I could do it. After rehearsing in my mind, I think it makes it easier to actually pull off.
During the balance of treatment, you can return to using imaginal exposure with O+A+C + VBA each time your clients get emotionally triggered during the week and don’t use a VBA. You can also encourage clients to relive problematic events using this exposure outside of session. Remind your clients that every time they enact a new values-based action they are building their emotion efficacy muscle.
Following is a synopsis of content covered in chapter 6: