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Kelly Wilson does a masterful job of framing the many different ways in which a

therapist grounded in mindfulness might skillfully nurture greater awareness and


self-knowing in his or her clients. His approach is a very creative use of mindfulness within the dyadic relationship, both verbal and non-verbal. Of course, it
is impossible to engage in authentically without continually listening deeply to
and learning from the myriad dyadic relationships we have within ourselves,
as he so aptly and honestly recounts. This book makes a seminal contribution
to the growing literature on ACT and its interface with mindfulness theory and
practice.
Jon Kabat-Zinn, author of Full Catastrophe Living and Letting
Everything Become Your Teacher and coauthor of The Mindful Way
Through Depression
This is a book of enormous breadth and depth, a book full of wisdom from an
internationally acclaimed clinician and researcher. Wilson builds bridges between
therapy traditions in a wonderful way.For those who already teach mindfulness
as part of their therapy, this is a must-read.For those who are yet to do so, this
book is the best invitation possible.
Mark Williams, professor of clinical psychology at the University
of Oxford and coauthor of The Mindful Way Through Depression
Wilson and DuFrene have provided therapists with the clearest understanding of
ACT and mindfulness that I have encountered. They explain the basic theory of
emotions and human learning in simple, clear, and understandable prose. Also,
I found this book rich in philosophical insights concerning the human condition.
Their models of assessment and intervention flow from this basic knowledge and
philosophy. This work will help all therapists see a new way to understand and
assess their clients suffering and potential for improving their lives. They will also
learn to construction treatment plans to make such a transition.
Raymond DiGiuseppe, Ph.D., ABPP, professor and chair of
the Department of Psychology at St. Johns University
This book provides the clearest description Ive seen of how understanding
both mindfulness and behavior analysis contributes to effective therapy. It also
provides unique, creative, and powerful exercises to help therapists cultivate
mindful awareness of their interactions with their clients to create life-changing
conversations.
Ruth A. Baer, professor of psychology at the University
of Kentucky

In this book Wilson, an internationally respected therapist, provides an outstanding and innovative overview of new trends in behavior therapy and mindfulness
and shares his insights into the complexities of what happens when we try to use
our own mind to heal the minds of others. Beautifully written, clear and bristling
with wisdoms from a very experienced therapist, this gem of a book will be a
pleasure to read and a source for much reflection and learning.
Paul Gilbert, author of Overcoming Depression and
The Compassionate Mind
There is tremendous change occurring in our collective thinking regarding empirically supported interventions. Mindfulness for Two portends the direction of this
change, where the scientist, therapist and client are motivated and affected by
the same set of principles. Mindfulness in general and ACT in particular apply
to both the client and the therapist, and Wilson and DuFrene are insightful,
emotionally honest, and pragmatic. This is a refreshing and timely contribution
to therapy process.
Thomas J. Dishion, Ph.D., director of the Child and Family
Center and professor of psychology and school psychology at
the University of Oregon
This is an extraordinary book. Wilson speaks to the reader directly and honestly.
He uses not only state-of-the-art scientific research but also his own most intimate
personal experiences, his considerable clinical wisdom, and even great poetry to
explain some of the most technical concepts in modern behavior analysis. The
book avoids getting bogged down in detailed theoretical analysis of questionable
relevance to clinical work. Of equal importance, it avoids the kind of unprincipled,
superficial technology common to many clinical guidebooks. Wilson demonstrates
how the ancient concept of mindfulness, when understood within the context of
modern behavior analysis and the new behavior therapy known as acceptance
and commitment therapy, provides fresh insights into the psychotherapy process.
Mindfulness for Two is a must-read for both novice clinicians seeking an introductory treatment of modern behavior analytic psychotherapy and for seasoned
clinicians who wish to deepen their understanding and skills.
James D. Herbert, Ph.D., professor of psychology and associate
dean of the College of Arts and Sciences at Drexel University

mindfulness for two


An Acceptance and Commitment
Therapy Approach to Mindfulness
in Psychotherapy

KELLY G. WILSON, PH.D.


WITH TROY DUFRENE

New Harbinger Publications, Inc.

Publishers Note
This publication is designed to provide accurate and authoritative information in regard to the
subject matter covered. It is sold with the understanding that the publisher is not engaged in
rendering psychological, financial, legal, or other professional services. If expert assistance or
counseling is needed, the services of a competent professional should be sought.
Distributed in Canada by Raincoast Books
Copyright 2008 by Kelly G. Wilson and Troy DuFrene
New Harbinger Publications, Inc.
5674 Shattuck Avenue
Oakland, CA 94609
www.newharbinger.com
All Rights Reserved
Acquired by Catharine Sutker; Cover by Amy Shoup;
Text design by Tracy Marie Carlson; Edited by Jean Blomquist
Kindness is reprinted by permission of the author, Naomi

Shahib Nye, from WORDS UNDER THE WORDS, Far


Corner Books/Eighth Mountain Press (1995).
Excerpts from Burnt Norton in FOUR QUARTETS by T.S. Eliot, copyright 1936 by
Harcourt, Inc. and renewed 1964 by T.S. Eliot, reprinted by permission of Houghton
Mifflin Harcourt Publishing Company.
Excerpt from DEATH OF A SALESMAN by Arthur Miller, copyright 1949, renewed
(c) 1977 by Arthur Miller. Used by permission of Viking Penguin, a division of Penguin
Group (USA) Inc.
What We Knew, by Carolyn Elkins, from Daedalus Rising, Emrys Press, 2002,
reprinted by permission of the author.
PDF ISBN: 978-1-60882-576-9
The Library of Congress has cataloged the hard cover edition as:
Wilson, Kelly G.
Mindfulness for two : an acceptance and commitment therapy approach to mindfulness in psychotherapy / Kelly G. Wilson, with Troy DuFrene.
p. ; cm.
Includes bibliographical references.
ISBN-13: 978-1-57224-631-7 (hardcover : alk. paper)
ISBN-10: 1-57224-631-6 (hardcover : alk. paper)
1. Mindfulness-based cognitive therapy. I. DuFrene, Troy, 1972- II. Title.
[DNLM: 1. Cognitive Therapy--methods. 2. Attention. 3. Meditation. 4. PhysicianPatient Relations. WM 425.5.C6 W749m 2009]
RC489.M55W55 2009
616.891425--dc22
2008052207

To Mississippi, a persistent teacher of the fine art of slowing


down.KGW
To the moment (well, one in particular: 28 April 2008, sometime
between 20:30 and 23:00 MDT)TD

The hardcover edition of this book came with a bound-in DVD-ROM


that contained copies of the worksheets youll find in Mindfulness for
Two, guided meditations in MP3 audio, and QuickTime video files that
demonstrated some of the clinical interventions described in the book.
All these files are available to you as a free download at:
22669.nhpubs.com

Contents

A Letter from the Series Editor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii


Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Prolegomenon
Finding My Way to Mindfulness for Two . . . . . . . . . . . . . . . . . . . . . . . xi
Chapter 1
Coming Face-to-Face with the Human Condition. . . . . . . . . . . . . . . . 1
Chapter 2
A Clinicians Guide to Stimulus Control. . . . . . . . . . . . . . . . . . . . . . . 23
with Emily Sandoz, MS, and Kate Kellum, Ph.D.
Chapter 3
The Hexaflex Model and Mindfulness from an ACT Perspective. . . 45
Chapter 4
Integrating Mindfulness Work into ACT. . . . . . . . . . . . . . . . . . . . . . 77
Chapter 5
Clients and the Present Moment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Chapter 6
Therapists and the Present Moment. . . . . . . . . . . . . . . . . . . . . . . . . 125

Mindfulness for Two

Chapter 7
Experiential Case Conceptualization . . . . . . . . . . . . . . . . . . . . . . . . . 149
with Emily Sandoz, MS
Chapter 8
Making Experiential Contact with Mindfulness. . . . . . . . . . . . . . . . 197
Epilogue
Slowing Down. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Appendix A
Using the Mindfulness for Two DVD-ROM. . . . . . . . . . . . . . . . . . . . 229
Appendix B
The Valued Living Questionnaire (Version 1) . . . . . . . . . . . . . . . . . . 231
Recommended Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239

vi

Dear reader,
Welcome to New Harbinger Publications. New Harbinger is dedicated to
publishing books based on acceptance and commitment therapy (ACT)
and its application to specific areas. New Harbinger has a long-standing
reputation as a publisher of quality, well-researched books for general and
professional audiences.
The therapeutic relationship is the base of psychotherapy. Functional
analysis is the base of traditional behavior therapy and behavior analysis. Mindfulness, acceptance, and values are increasingly forming the
base of modern cognitive and behavioral methods. Mindfulness for Two
is the first book to bring these strands together in a way that empowers
and transforms them all. It is a groundbreaking volume that will leave
few readers unchanged. Whether new to ACT or experienced ACT
therapists, readers will find themselves drawn to a cusp and asked to
pause therenot because they are being abandoned, but because they
are being asked to experience what is possible when the question is as
important as the answer.
Mindfulness for Two carefully defines mindfulness from an ACT perspective and shows how it applies to the moment-to-moment interactions between therapist and client. It develops an approach to diagnosis
and case conceptualization thatrequires the clinician to slow down and
mindfully attend to what is present. The functional conceptualization
that this process yields is tightly linked to treatment and to what we are
learning in behavioral science. Each ACT process is used to help cast a
new light on the situation faced by clients and clinicians. The book challenges therapists to give up comfortable linearity and instead do their
work inside a flexible space where every ACT process is available and
potentially relevant to every therapy moment.
Kelly Wilson, Ph.D., is a leading developer, trainer, researcher, and
thinker in contextual behavioral science in general and ACT in particular. Mindfulness for Two speaks with Kellys voice, amplified by his cowriter Troy DuFrene. That voice, like Kelly himself, is passionate, caring,
and insightful. An author of the original ACT volume (Hayes, Strosahl,
& Wilson, 1999), Kelly has trained thousands, and his training experiences show in these pages. The book teaches. Details are given and
insights shared. The combination of head, hand, and heart that is ACT
exudes from every page.
As part of New Harbingers commitment to publishing books based
on sound, scientific, clinical research, we oversee all prospective books
for the Acceptance and Commitment Therapy Series. Serving as ACT series
editors, we comment on proposals and offer guidance as needed, and use

Mindfulness for Two

a gentle hand in making suggestions regarding the content, depth, and


scope of each book.
Books in the Acceptance and Commitment Therapy Series:

Have an adequate database, appropriate to the strength of


the claims being made.

Are

theoretically coherent. They will fit with the ACT


model and underlying behavioral principles as they have
evolved at the time of writing.

Orient the reader toward unresolved empirical issues.


Do not overlap needlessly with existing volumes.
Avoid jargon and unnecessary entanglement with proprietary methods, leaving ACT work open and available.

Keep the focus always on what is good for the reader.


Support the further development of the field.
Provide information in a way that is of practical use
readers.

to

These guidelines reflect the values of the broader ACT community.


Youll see all of them packed into this book. Kelly worries periodically that
his colleagues will demand more citations and text thats denser empirically. Possibly, but those who know the literature know that this book is
on firm empirical ground, and when it reaches into the unknown it does
so in a way that plausibly extends what evidence suggests. This series is
meant to offer professionals information that can truly be helpful, and to
further our ability to alleviate human suffering by inviting creative practitioners into the process of developing, applying, and refining a better
approach. This book provides another such invitation.
Sincerely,
Steven C. Hayes, Ph.D., Georg H. Eifert, Ph.D.,
and John Forsyth, Ph.D.

viii

Acknowledgments

Writing this book has been part of an ongoing process for me. In 1985, I
began a journey out of an incredibly dark place. All along the way there
have been people who have nurtured mepeople who saw something in
me that I couldnt see in myself. I would like to acknowledge my teachers, especially Steve Hayes, Linda Hayes Parrot, Sam Leigland, Richard
Baldasty, Dexter Amend, Bill Follette, Victoria Follette, and Lois Parker.
These and many others brought me to this day. Sometimes I tell people
that my current job is to travel around the world falling in love with
peoplea pretty good gig if you can get it. Back in 1985, I could not have
imagined finding myself in the world I now inhabit.
I want to acknowledge New Harbinger. The NH folks have been
terrific and supportive. I especially want to thank Matt McKay. Matt,
with tears in his eyes, asked me for this book at the Association for
Contextual Behavioral Science Summer Institute in 2007. Matt said that
I didnt have to write a word, that I could just talk into a recorder and
send it off to New Harbinger. Of course, this book was not written that
way, but what Matt said seemed to free me up to write in my own voice.
Thanks also to Catharine Sutker for pursuing me for the past half dozen
years and for introducing me to Troy DuFrene. I feel that I have made a
friend for life in Troya true brother.
On the mindfulness front, I extend the warmest thanks to Jon KabatZinn for his kindness and support. Jons guidance in planning my sabbatical and the lovely week with him and Saki Santorelli at Mt. Madonna in
California were priceless. I would like to acknowledge John McNeil for
his kind assistance in helping me talk and think about the relationship

Mindfulness for Two

between my work and Eastern philosophical and practice traditions. And


I offer many thanks to Mark Williams for his gentle openness over the
years and to Barry Silverstein for pushing me to think harder about the
ACT-mindfulness connection.
The video segments associated with the book wouldnt have been
possible without the heroic assistance of Ragnar Storaasli and his students and colleagues in Denver. My warmest thanks go out to Ragnar
and to Cari Cornish, Lisa Michelle Fuchs, Matt Heermann, Katherine
Holt, Bennett Leslie, Ellen Lewis, Emily Sandoz, Joanne Steinwachs, and
Brandon Ward. Im also very grateful to Jay Wren and the kind people
at Agren Blando Court Reporting & Video, Inc., for their camera and
audio work.
I must acknowledge my most faithful lab codirector Kate Kellum and
the grad students in my lab and supervision group at Ole Miss who have
let me try ideas out on them over the years. Thank you to Amy Murrell,
Laura Ely, Miguel Roberts, Sushma Roberts, Lisa Coyne, Rhonda
Merwin, Catherine Adams, Jonathan Weinstein, Chad Drake, Jenny
Kitchens, Leslie Rogers, Stephanie Nassar, Emily Sandoz, Regan Slater,
Scott Bethay, Nadia Lucas, and my most recent find, Lindsay Martin.
Lastly, I want to thank my wife Dianna and my daughters Sarah,
Emma, and Chelsea for loaning me out to the world on a very frequent
basis over the past ten years. None of this would mean much without
you. Set me as a seal upon thine heart, as a seal upon thine arm: for love
is strong as death.

Prolegomenon

Finding My Way
to Mindfulness for Two

In June 2006, I found myself presenting a workshop at the International


Mindfulness Conference in Bangor, Wales. The invitation surprised
me. Id thought some about the relationship between the work I do and
mindfulness before that conference, though not really a great deal. At
the conference, I prepared the audience to do an exercise called the
Sweet Spot. The exercise, described later in this book, is a meditation for
two on a sweet moment in life. As I began putting the audience together
in pairs for the exercise, I noticed a gentleman at the back of the room.
He had come in a little late that morning. I went to the back of the room
and invited him to join the exercise. He declined, saying that hed just
flown into the UK and was feeling a bit jet-lagged. In the end, we had
an odd number of participants without him. He was a good sport and
agreed to join us. We did the exercise, debriefed a bit, and then went to
get something to eat.
At lunch, this fellow whod been sitting in the back of the room
came up to me, reached out and shook my hand, and said, Hello, my
name is Jon Kabat-Zinn. What can I say? I didnt recognize him from
his book covers.
Later that day, during the coffee break, I confided in Jon that people
sometimes asked me if I had a mindfulness practice. I told him that I
never knew exactly how to answer. I told him that I didnt sit on a cushion
for forty-five minutes each morning.

Mindfulness for Two

But, I said, I do this, referring to the meditation for two we had


been doing on the sweet spot and to similar work with clients. So, what
do you think? I asked Jon. Is this a mindfulness practice?
If this isnt mindfulness, I dont know what is, Jon replied.
This vote of confidence from a man who has done so much to
promote the concept of mindfulness means a lot to me, and it gives me
some comfort when I describe the contents of this book as a part of a
mindfulness practice.
The aim of this book is to get you acquainted with something I call
mindfulness for two. This is, in short, a collection of attitudes, sensitivities, and practices, the goal of which is to increase conscious attention to
the present moment on the part of both the therapist and the client in
a psychotherapeutic situation. Mindfulness for two, at least as Im going
to talk about it in this book, is inseparable from the larger body of work
called acceptance and commitment therapy (ACT), a branch of cognitive behavioral therapy that integrates mindfulness and acceptance
strategies with values-based committed action as a means to increase
psychological flexibility. Mindfulness for two is also resonant with the
many traditions of mindfulness, although it isnt necessarily of any one of
them, having goals that are unique to the psychotherapeutic relationship
as it is developed in ACT.
Many of the leaders of the application of mindfulness to health care
today began with an interest in mindfulness born of personal experience.
Folks such as Jon Kabat-Zinn, Marsha Linehan, and Alan Marlatt had
meditation practices of different sorts for many years. They saw benefits
from their personal practices and sought ways to bring these benefits to
their clients, adapting meditation practices for individuals who suffered
from various physical and psychological difficulties.
This wasnt my path. My own path to teaching mindfulness didnt
emerge from the translation of a formal mindfulness practice into an
application for use in health care. I didnt come to mindfulness out of my
strength in mindfulness. I didnt come to mindfulness out of any strength
at all. I came to mindfulness out of a weakness: my own mindfulness
practice with clients came from my complete inability to listen to them
carefully.
Its really remarkable how well a person can get by without listening.
Most conversations dont require a great deal of attention. We can drop
in and out of them, nodding occasionally. Even if we lose our place, we
can readily catch up. As with driving, if were well practiced, we can
engage in a conversation almost automatically, with very little attention.
Perhaps youve had the experience while driving of suddenly becoming
xii

Finding My Way to Mindfulness for Two

aware that youve driven a dozen miles without the slightest idea of what
you passed or what you had been doing while behind the wheel. When
this sort of thing happens, you snap to attention, but unless youve driven
off the road, there are no particularly serious consequences.
When you have a similar experience while engaged with a client,
though, the stakes are a lot higher. I recall with incredible clarity sessions in which I would suddenly find myself sitting in front of a client
who was pouring her heart out while I had no idea what she was talking
about. This is very embarrassing to admit, yet it is very true. Needless to
say, this problem with attention was a real deficit for me as a therapist, as
someone for whom careful listening is a core skill.
The truth for me, though, is that I have a busy mind. Ive always been
that way; as a young student, half of my attention was on my teachers in
school and the other was out the window, watching the clouds, thinking
about what would happen later and what had happened before. It isnt
surprising that I carried this tendency over into the therapy room. I was a
skillful enough conversationalist to keep clients from noticing my lapses
in attention, but I recognized that the lapses were occurring. And I felt
bad. Unlike the driving example, there were consequences. My clients
were only being half heardor, worse, not heard at all.
Ive had a long, unsuccessful history of privately promising myself to
mend various of my ways. Ive found that its typically more fruitful for
me to confess my misdeeds publicly and then set things right according
to what it is that I value. Thats what I began doing with clients. I would
say something like Im sorry, but Ive missed some of what you were
saying, and its important that I really hear you. So, if you would, lets
back up just a bit. Id like you to say again what you just said, and let me
listen. Let me listen until I hear the heart of what you are saying.
I recall a client I saw in therapy in the early 1990s as the first instance
in which I can clearly see seeds of my current practices. I was treating
a young woman, an artist. She was very bright and funny and odd and
troubled. Although she was otherwise quite articulate, she had very little
insight into her own emotional life. As I sat and listened to her, I would
occasionally see the smallest transient glimmer, a tiny hint of emotion
that would evaporate like a single raindrop on a hot summer sidewalk. I
would ask, What was that? She would reply she had no idea at all what
I was talking about.
She liked and respected me though and was willing, when I asked
her, to back up in the story and tell the part again that had stirred the bit
of emotion. It often took several attempts. She would come upon the bit
of difficult material. I would see that transient shift in her affect. Then
xiii

Mindfulness for Two

her pace of speech would quickly speed up, and wed be on to a new
topic. We often had to back up and slow our pace down many times in
the course of a session.
Eventually we learned to stop and linger at these cusps, these small
transitions. And in these margins we found a lovely richness. We found
much pain, which speeding along held at bay. But we also foundmixed
with those tearslaughter, love, and compassion. She learned to stop
on her own, outside sessions, and linger at those interstices. She drew on
this new experience to produce a series of paintings, which she displayed
in a show called Stopping. I still have a poster from the show. And I still
remember those moments we spent together, learning to stop.
Since that therapy experience, there have been grants, new academic
and research posts, many new students, and dozens of workshops, all of
which seem, in retrospect, to have led me inexorably from a complete
inability to listen well to the mission of teaching mindfulness for two, a
different sort of listening and speaking.
In writing about and conducting trainings using this material, Ive
found myself filled with questions. What if we took that focused yet
flexible, open, and accepting attention that we cultivate on the meditation cushion into our interactions with clients, trainees, and peers? How
would those conversations be transformed? How would they differ from
more ordinary conversations?
The adoption of a formal mindfulness practice isnt part of ACT,
although its in no way inconsistent with ACT. This book describes the
use of mindfulness processes in our interactions with clients; its much
less concerned with formal mindfulness practice. Since its not in my
field of expertise, Im happy to leave the teaching of practices such as
sitting meditation to those better qualified.
What I am expert in is behavior analysis and its application to psychological difficulties. The rise of mindfulness-oriented work in recent
years has spurred me to think more carefully about the role of mindfulness processes in ACT. Although the seeds of it were there from the
start, its only recently that I feel I have begun to grasp how integral
mindfulness processes are to other therapeutic processes in ACT.
In his lovely book On Becoming a Person, Carl Rogers says, What is
most personal, is most general (1995, 26). Ive bet my career that Carl
Rogers is right. This book is personal. Its personal for me, and I hope
youll allow it to be personal for you. I realize theres some risk in writing
predominantly to you, the reader, directly. You may find it intrusive that
I speak directly to you. If thats so, please forgive me. Many if not most
psychology texts are written to a remote third person; I realize youll be
xiv

Finding My Way to Mindfulness for Two

used to this more formal but perhaps less engaged voice. But when we sit
down with our clients, their very presence in the room with us invites to
be more present with them, to be more aware of where we are in relation
to them. My hope is that, by addressing you directly, Ill be inviting you
to be more aware of where you are in relation to me, to the discussion in
this book, and to your clients.
Also, ACT doesnt draw any hard lines between clients and therapists, so it seems only right that I not draw any hard lines between
you and me. Many of us in the ACT-treatment-development community think that the same processes that create obstacles for clients create
obstacles for therapists. We share this sensibility with fellow travelers in
the mindfulness community. Further, we think that the best way that
therapists can learn about ACT principles is by examining them in our
own experiencea sort of self-as-laboratory perspective.
Consider this foreword, then, as a sort of informed consent. If youre
offended by me speaking directly to you, or if youre unwilling to sit with
hard things, both your own and your clients, this book isnt for you.
However, if youll accept my intrusion for a few pages, this book may
provide experiential learning in addition to the usual didactics that fill
our bookshelves.
Before we go any further, let me call your attention to the DVD-ROM
bound into the back of this volume. The disc contains QuickTime video
that demonstrates some of the things Ill be discussing as we go along. Ill
reference some of the content on the disc from time to time. For a more
detailed description of the contents of the disc and how to take advantage of it, flip back to Appendix A.
Im grateful to all those clients who suffered through my learning
curve and who helped me to find my way in that therapy room. I also owe
Judith Soulsby, who engineered the invitation to Bangor in 2006, a great
debt for putting me in a position that required me to think hard about
ACT and mindfulness. In the days since that workshop in Bangor, the
relation between the present-moment-focused ACT work I do in training
and mindfulness has thoroughly occupied my thinking. People who have
been to my workshops over the past couple years have been subjected to
my developmental process, much like the clients who came before them.
I owe all of them a debt and hope that there are things in this book that
partly repay their patience with me.

xv

Chapter 1

Coming Face-to-Face with the


Human Condition

My psychology is personal. Its my hope that in this chapter and those


that follow, Ill make this psychology personal for you too. Its my conviction, my working assumption, that theres a commonality and ubiquity
to human suffering and that if were willing to sit in kindness with our
own, well be able to hear the hearts of our fellows. Though important,
the hearing of hearts isnt the whole of this work. But its an important
first step: the fostering of a place from which our clients and we can work
together.
Empirical clinical psychology has had a hard time seeing the unity
of human suffering, though the data lie all around us. Why? I believe
that the unity of human suffering is obscured by the very categories we
impose upon it. This book is an argument that there is value in looking
past the categories for a moment at least and in letting what we see there
change us.
In this as in many other matters, sometimes poets have a clearer
view:
Before you know what kindness really is
you must lose things,
feel the future dissolve in a moment
like salt in a weakened broth.
What you held in your hand,

Mindfulness for Two

what you counted and carefully saved,


all this must go so you know
how desolate the landscape can be
between the regions of kindness.
...............
Before you know kindness as the deepest thing inside,
you must know sorrow as the other deepest thing.
You must wake up with sorrow.
You must speak to it till your voice
catches the thread of all sorrows
and you see the size of the cloth.
Naomi Shahib Nye, Kindness (1994, 4243)
Its my sense that, with the best of intentions, we lose sight of the
size of the cloth, right there in the room with our clients, and losing sight
of that cloth has a cost both to us and to them. So I invite you to come
along on this next part of our journey. Ill warn you in advance that there
are some stops on this trip where the view may be both panoramic and
painful.

THE GREAT FACT OF HUMAN SUFFERING


Go, go, go, said the bird: human kind
Cannot bear very much reality.
T. S. Eliot, Burnt Norton (1991, 176)
And we mental health professionals, how much reality can we bear? The
prevalence of particular psychiatric diagnoses can be misleading. Taken
singly, diagnostic categories are relatively rare. In a sample of fifteento fifty-four-year-old Americans, we can expect only 2.8 percent to be
diagnosable with drug dependence, 3.1 percent with generalized anxiety
disorder, and 2.5 percent with dysthymia within a given twelve-month
period (Kessler et al., 1994). Theres a certain safety in the rareness of
these categories. Their uncommonness puts a bit of distance between us
and suffering, between our loved ones and suffering. The categories are
somewhat abstract and not personal.
Setting aside the categories for a moment, however, we see a much
different picture. In the same study cited above (Kessler et al. 1994), a
survey of only fourteen of the categories in the Diagnostic and Statistical
2

Coming Face-to-Face with the Human Condition

Manual of Mental Disorders (DSM), report that more than 29 percent


of fifteen- to fifty-four-year-olds experienced sufficient symptoms within
the last twelve months to qualify for at least one Axis I psychiatric diagnosis. Among fifteen- to twenty-four-year-olds, the rate was 34 percent.
Again, this was not a clinical sample or an at risk sample. It was a
representative community sample.
Even these numbers tell only a partial story about human suffering.
These statistics include only fourteen of the dozens of DSM Axis I disorders. They dont include any Axis II disorders. They also dont include
the myriad forms of compromised adjustmentthe DSM V-codes. They
dont tell us how many live in marriages filled with acrimony or perhaps
empty of any emotion at all. They dont tell us whether this person finds
her work meaningless or if that person cannot talk to his children.
These statistics also dont include subclinical cases. Should the
person who feels depressed most of the day, nearly every day, who has
lost pleasure in all or most all activities, who feels worthless and has
no energy be relieved because she doesnt have that fifth symptom and
therefore doesnt meet criteria for depression? Is there any difference
in kind between the person who has four and the person who has five
symptoms?
In order to bring this point home more forcefully, consider these
statistics as you walk through a typical day. Think about the people who
work in your office or building. Let your attention move from one face to
the next as you walk down the street. Count people silently as you meet
them: one, two, three, one, two, three. Let yourself notice that approximately every third could be diagnosed this year if only the right set of
questions were asked. Notice also that, for the most part, they look just
fine. And how about you?
Suicide and suicidal ideation give us another telling window into
human suffering. Suicide itself is relatively rare. In the United States,
there are approximately eleven deaths by suicide per 100,000. In other
words, about 1/100th of a percent of the population will die by suicide
(Centers for Disease Control and Prevention, n.d.). However, one study
(Chiles & Strosahl 2005) found that 20 percent of a community sample
reported a two-week period of serious suicidality, including the identification of a plan and the means to carry it out. They reported an additional 20 percent who had the ideation but without a specific plan. This
suggests that nearly half the group was likely suffer to such an extent that
they seriously considered ending their own lives as a way to end their suffering. It doesnt strike me as reckless to imagine that this statistic could
apply more broadlymuch more broadly.
3

Mindfulness for Two

If it does, what might this mean for you? It might mean that half of
the people you know have had, or will have, a moment of such pain and
despair that death seems a kinder option than soldiering on. But will
they tell you? No. Not half or likely even one in a hundred will ever say
a word. Theyll come to work, to class, to therapy, to the dinner table.
Youll ask them how they are. And theyll tell you theyre fine.
Suicide seems safe as an obscure statistic. Its even pretty tolerable,
if worrisome, for most mental health professionals to talk about when it
strikes at work or at a local school. Yet completed suicide is rare. Even
when it strikes in our town or at work, it recedes from awareness before
long.
But really consider the implications of nearly half the population
giving serious thought to self-slaughter. Let yourself recognize whom this
is about. As you move through your day, pause for just a moment as you
greet each person and count silently again: one, two, one, two, one, two.
Let yourself hesitate and glance a moment and look into those eyes. Let
yourself wonder. Dont do anything about it. Just pause and wonder. At
the next staff meeting, cocktail party, or PTA social, let your eyes move
about the room. Let it sink in that nearly half of those youre seeing will
know this dark night of the soul. And, most likely, the next day theyll
come into work, and theyll be fine.
Even that is too abstract. How many brothers and sisters do you
have? Stop a moment and close your eyes. See their faces, and let yourself
quietly say their names as you do. And count again. One, two, one, two.
See if you can see, as you look into those eyes, hints of that suffering
just the other side of fine.
Worse stilldo you have children? One, two, one, two. See if you
noticeright in this momenthow much you want me to stop, to move
on to the next point. And, in that rejection, we find the altogether
human reaction to suffering. We want to hold it distant or not at all. In
that rejection, we also see the source of all that silence, we see why the
automatic answer to How are you? is Fine.
And how about you? Do you know that dark night? And how are
you? And who knows about that?
I was presenting this material recently, and a young man in the audience said somewhat angrily, Could you stop with the gruesome personal
examples?! I dont want to think about my own children being suicidal. It
would be easier to understand this if you didnt do that.
I did fall silent. I stood speechless for a moment in front of a hundred
people. And I did stop giving personal examples. But in that moment, in
the front of that room, I thought hard about Eliot: Go, go, go, said the
4

Coming Face-to-Face with the Human Condition

bird: human kind cannot bear very much reality. I suspect that the pervasiveness of human suffering isnt any easier to understand without the
personal examples, but I have no doubt its easier to tolerate. We so want
suffering to be an abstraction, to be about someone else, somewhere else,
or at least somewhen else. As an old Greek saying puts it, luck is when
the arrow hits the other guy.
I went silent that day, but in my hesitation, I became keenly aware of
the cost of that silence. I paid a price personally. So did all of the people
in the workshop. In a way, the countless people who go silent in the face
of suffering every day pay a price in that moment of concession. Why is
it that we, our brothers, sisters, friends, and, yes, even our own children,
will surely suffer and likely suffer alone? We all bear some responsibility
and possess some ability to respond. But we remain silent about our own
suffering. And, in sometimes subtle and sometimes not-so-subtle ways,
we conspire to silence suffering around us.
When talking with clients about suffering and especially suicidality,
Ive sometimes gone for a walk with them and counted: one, two, one,
two, one, two.
That one? And that one? And maybe that one.
I sometimes ask whom my clients have told. Most commonly they
answer, No one. Them too, I reply, nodding toward the ones we just
counted.
If they admit to having told someone, I ask, How did that go? The
most common response is near apoplexy on the part of the person in whom
they confided. This is often true even of mental health professionals.
Please be clear: Im not advising my clients to go out proclaiming their
suffering. This exercise of wondering how many of those we encounter
each day suffer in silence is an act of appreciation, not a prescription for
future action. Having to tell is as much a trap as having to remain silent.
The exercise is a chance for us to sit with suffering and appreciate the
size of the cloth.
What would it mean for us, as professionals, if we let ourselves see
that the supposed rarity of any given mental health diagnosis was a just
a trick of perception? The result of looking at the whole cloth of human
suffering as though it were a thousand separate threads? What would it
mean if we all learned to catch the thread of all sorrows? If we truly
apprehended the vast size of the cloth into which we, client and therapist
alike, are woven?
Im suggesting another path we can take. What if our willingness to
let this suffering come close allowed us to sit near our clients and to truly
hear the heart of their suffering? Really its not even so much letting it
5

Mindfulness for Two

come close as it is letting ourselves see how close it already is. Could it
be that in the same ways that we conspire to silence suffering, we could
begin to allow suffering to be present, for the good of our clients, ourselves, and those we love?

EXERCISE: Letting Suffering Get Close


Let your mind come to rest on some of the figures listed above, especially
the statistic that more or less half of us have known pain and desperation so acute and so severe that weve seriously considered taking our
own lives. Bear this statistic in mind as you engage in this simple exercise. Before you begin, find some way to time yourselfan egg timer, a
stopwatch, an alarm clock. Allow about three minutes to consider each
of the following scenarios. Just sit with them; let them be. Dont try to
understand them, solve them, or sympathize with them. Just notice them;
let them get close to you. When you finish with one scenario, open your
eyes and take a few breaths. Then move on to the next.
Be warned: Your mind will literally do backflips to get you to run
away from these scenarios, more so as they progress. When it does, thank
it for the effort and gently return your attention to the scenario.
Sit comfortably in your chair. Close your eyes and take a few deep,
slow breaths.
1. Imagine someone you know casuallya chance acquaintance, an occasional coworker, the friend of a friend
someone whose features you know but whose personal story
might be less familiar to you. Picture this person sitting alone
in a room, deep in sorrow. Imagine that he has just learned
of the loss of someone dear. Allow your awareness to come
to rest on this persons face. Notice the details of his expression. Do you see tears? Trembling? Shallow or rapid breath?
Is the hair across his brow in disarray? Keep allowing your
awareness to wash over this person like water, just appreciating his sorrow and loss without doing anything with it, until
your timer goes off.
2. Now imagine someone you care abouta dear friend, a
sibling, your spouse or child. Imagine that this person is
struggling with an overwhelming feeling and abiding in
great pain. It might be a profound sense of hopelessness,
6

Coming Face-to-Face with the Human Condition

extraordinary anxiety, or a blinding rage. Let your attention


fall on her body, hands, and face. See the terrific suffering
in her eyes. Notice how the humor, vitality, and engagement
that you may be used to seeing in this person seem to have
drained away. Imagine her totally alone, with no one to turn
to, feeling lost and alienated. Even though your awareness is
sharply focused on this person, gently let go of any urges you
feel to reach out to her. Just allow yourself to be aware of her
pain until your timer goes off.
3. Finally, imagine a person, perhaps a client, whom youre concerned about, someone you feel youd like to help but maybe
cant help fast enough or even cant help at all. Imagine this
person, sitting alone in a darkened room. Although he is in
great pain, imagine that you can see a look of cold, determined resolve on his face. Allow yourself to slowly, slowly
become aware that you are watching this person on the
last day of his life. Nothing you can say, nothing you can
do will alter the inexorable course that, set in motion years
and years ago, will now proceed to its conclusion. There is
nothing to be solved now, no solutions to be found, no protocols to be followed, no avenues to explore. Let yourself
simply witness this person in these last hours. Notice what
your attention falls on in him, and also notice what comes
up in you. Do you long to reach out to him? Do you want to
figure out what has happened? Do you try to turn and run?
As best youre able, remain a witness to this person, calm
and present, until your timer goes off.

WHY ACKNOWLEDGE SUFFERING?


Im sometimes asked why we should spend time lingering with the ubiquity of suffering. People ask, Isnt it normal to act to reduce suffering?
Of course. Its entirely normal. Its also normal for the dog that has been
hit by a car to bite the stranger who tries to rescue it from the middle of
the road. But the bite doesnt help the dog get to the veterinarian.
When the source of suffering is lions and tigers and bears that
might attack and eat us, withdrawal is entirely adaptive. But what are
7

Mindfulness for Two

the consequences of withdrawing from psychological sufferingfrom


embarrassment, from grief, from fear? What if withdrawing from suffering entails withdrawing from the sufferer also? As clinicians, we must
ask ourselves, would I be willing to sit with suffering if it allowed me to
sit with my clients?
Im not suggesting that we cultivate a morbid preoccupation with
suffering. Im not even suggesting we spend a great deal of time with
it. I am suggesting that, to the extent were intolerant of suffering, well
feel compelled, consciously or unconsciously, to turn away from it in our
clients and ourselves. Sebastian Moore puts it this way:
The rejection of our common fate
Makes us strangers to each other.
The election of this common fate, in love,
reveals us as one body.
Sebastian Moore (1985, 94)
When we turn away from suffering, we miss the other things, rich
and varied, that are inextricably linked to suffering. Values and vulnerabilities are poured from the same vessel. Consider the ways you have
been most deeply hurt in your own life and see if each hurt was not connected to a deeply held value. The betrayal that led to divorce wouldnt
have hurt had you not valued the trust and love of your spouse. The
taunting of the kids at school wouldnt have hurt except that you valued
companions and the respect and regard of your fellows. The death of your
mother wouldnt have hurt, except for the great love you bore for her.
I dont know of a way to breathe in without being willing to breathe
out. I dont know of a way to love without being willing to feel the sting
of loss. I care about you, the reader, even though we may not have met,
but I dont know how to say these words without knowing also the fear
that they will seem hollow to you.

AMBIGUITY AND SUFFERING: THE BEAR


AND THE BLUEBERRIES
Humans dont just suffer when things are bad. They also suffer when
things might be bad. In the experimental literature on nonhumans, it
is readily shown that organisms prefer environments in which painful
things are predictable over environments where they are not (Abbot,
8

Coming Face-to-Face with the Human Condition

1985; Badia, Harsh, & Abbot, 1979). If pressing a lever changes a rats
environment from one in which shocks come at random times into an
environment in which they occur at regular intervals, the rats will press
to produce regular shocks. This is so even when the absolute number,
duration, and intensity of shocks are identical.
Humans are like that too. It isnt difficult to imagine why this might
be so. There are lots of ways for a species to survive. If youre a squid, you
spawn tens of thousands of babies. If five or ten thousand of your kids get
eaten, survival of your genes isnt especially threatened. But we humans
arent so prolific. We usually have our babies one at a time or, more rarely,
in twos or threes. If even one of your kids gets eatenwell, its likely to
be the low point of your day. So for us, as for all creatures with relatively
low reproductive rates, characteristics that lead to the survival of the
individual organism are at a premium.
Lets look at the relationship between ambiguity and survival in our
often hostile and dangerous world. Imagine you and I are two early hominids out on the savanna. We see, off on the horizon, a vague shape.
Is that a bear or a blueberry bush? I ask.
I think its a blueberry bush, you reply.
A little tentatively, I say, I dont know. It might be a bear.
No, I really think it is a blueberry bush.
Well, Im going back in the cave, just in case.
You shrug and dash off into the distance. Later, you come back to
the cave, belly distended, talking endlessly about how fabulous the blueberries were.
They were the biggest, juiciest blueberries youve ever seen! you
cry. I can hardly move Im so stuffed!
That night I go to bed a little unhappy and a little hungry. Imagine
that this scenario plays out several times. Each time, I express my concern
that it might be a bear and go back to the cave, and each time you
express your conviction that its a blueberry heaven, just like last time.
One afternoon you go sauntering off with your blueberry basket on your
arm, but you dont come back to the cave. When youre still not home
the next morning, I get up and go over to your part of the cave, gather up
your stone ax, that mammoth hide of yours Ive always secretly coveted,
and, most importantly, your mate.
If you go off to eat those blueberries enough times, eventually the
shape on the horizon turns out to be a bear, and that day youre the bears
lunch. For us, the central evolutionary imperative is that its better to
miss lunch than to be lunch. Were capable of missing lunch many, many
9

Mindfulness for Two

times, but we can only be lunch once (and after that, perhaps dinner and
breakfast, but thats largely up to the bear).
Were the children of the children of the children (and so forth) of
the ones who played it safe and went back to the cave. As we evolved
for millions of years in an unforgiving world, natural selection weeded
out the brazen and the brash. Our ancestors, the ones who survived and
passed on the genetic material of which we are all made, were selected
for their caution. They were the ones who assumed that whats bad is bad
and whats ambiguous is bad too.

BETTING WITH YOUR LIFE!


The State of the World
Its a bear.

Its a blueberry bush.

I bet its a bear.

I miss being lunch


(and survive).

I miss lunch
(and survive).

I bet its a blueberry


bush.

I am lunch!

I get lunch!

This means that ambiguity itself will often be experienced as aversive.


Clinically, ambiguity is often a source of considerable suffering. Consider
the internal dialogue of someone addicted to heroin who has made a
commitment to abstinence. Will I, wont I? Will I, wont I? Will I, wont
I? And the truth? No one knows. The person with the addiction doesnt
have a crystal ball; she cant see the future. Theres only one way to know
for certain, only one way she can eliminate that dense ambiguity, and
thats to stick that needle in her arm. In the moment she uses, she gets
a moment of relief from the ambiguity. And, altogether too often, that
moment is enough. Somehow right in the middle of the relapse, or right
before a relapse, stories about next time seem much more plausible.

EXERCISE: Sitting Inside Significant Questions


We dont have to appeal to behavior as extreme as heroin addiction to
find the seeds of this reluctance to sit with ambiguity that lie within all
of us. Consider the things youd like to do in your own life. Especially
10

Coming Face-to-Face with the Human Condition

consider things with fairly high stakes: should I get married or divorced,
have children, change careers, or start a new business? Ponder one of
these or another that feels significant to you. Try doing this while intentionally not deciding one way or the other, and without evaluating or
drawing any conclusion. Rather than decide or conclude, let yourself
wonder what you will do.
If you notice yourself deciding or weighing the pluses and minuses,
gently let go of that process and come back to the question. Repeat the
question gently to yourself, listening with care to each word. If you find
yourself concluding, Well, Im not really going to do that or Sure,
thats a good idea, let yourself notice that you are drawing conclusions
about an unknown future. Your conclusion may indeed be the most
likely outcome, but sometimes very, very unlikely things happen. As
many times as you find yourself concluding or deciding, gently come
back to the question and linger. Let yourself wonder for a few minutes.
Notice also how quickly you are ready to move on to the next thing on
your to-do list.

This is jumping the gun a little, but theres another exercise in this
vein in chapter 6 called To Eat or Not to Eat. It serves another purpose
there, but if this idea of finding and just inhabiting the edge between
doing and not doing intrigues you, you can skip ahead and take a look.

LEARNING TO LOVE AMBIGUITY


Most of the things in life we truly care about are very ambiguous, and
if we cant tolerate ambiguity, we are doomed to act in the service of its
elimination. Ill come back to this topic repeatedly throughout the book,
as it will be central in our discussion of work with clients.
Learning to love ambiguity can be very powerful. By love here, I
dont mean the feeling or state of love. I mean love as an act: to care
for or relish ambiguity, to make an honored place for it at the table, to
sit with it quietly and see what it has to say to you. There are things in
the midst of ambiguity that cant be seen elsewhere. The poets understand this better than psychologists, though not necessarily in a way that
readily informs clinical practice.
At the still point of the turning world. Neither flesh nor

fleshless;
11

Mindfulness for Two

Neither from nor towards; at the still point, there the dance

is,
But neither arrest nor movement. And do not call it fixity,
Where past and future are gathered. Neither movement
from nor towards,
Neither ascent nor decline. Except for the point, the still

point,
There would be no dance, and there is only the dance.
T. S. Eliot, Burnt Norton (1991, 175)

THE UBIQUITY OF HUMAN


PROBLEM SOLVING
The complement to the ubiquity of human suffering is the ubiquity of
human problem solving. Wherever you find a human, you find a problem.
A simple breathing meditation provides a marvelous example of the near
impossibility of separating humans from their problem solving, and it
gives us a clear window through which to observe the human condition.
Give a human an altogether simple task and hell find a problem to solve.
Its pretty much a given that if you have a pulse, you have a problem. And
if you dont, give it a minute. The human capacity for problem solving
seems near limitless. Of course, we get little reprieves here and here. But
if it were common or easy to let go of problem solving, there wouldnt be
a hundred meditative traditions to teach us the altogether simple skill of
repeating a word or phrase, or sitting, or breathingof taking a moment
to not problem solve.
Try it yourself.

EXERCISE: Solving the Problem of Solving the


Problem of Solving the Problem of
You have everything you need to try this exercise. You know how to
breathe. You know how to count to ten. You know how to sit. Choose
a time when you have a bit of time on your hands without any pressing
responsibilities.
12

Coming Face-to-Face with the Human Condition

Sit down in a comfortable position. Gently close your eyes. Begin to


count your breaths from one to ten, starting again when you reach ten.
Then, watch the show.
Okay. Here I go: one, twoah, my back hurts a little.
You adjust a little and solve the back-hurting problem.
Ahh, thats better. One, two, threegee, my knee hurts a little.
You move your knee a little bit and solve the knee-hurting problem.
There we go. Much better. Now Im ready. One, two, three, fourthis is
going pretty well, feels niceOops! Where was I?
Then you solve the wandering-mind problem. And so forth.
As you go, notice how effortlessly your mind moves to solve problems and even invents problems for you to solve if none readily present
themselves.

THE PROBLEM WITH PROBLEMS


There are very good evolutionary reasons why problem solving is so essential to our nature. If we go back to the savanna and imagine that there
was variability in the propensity to problem solve, its hard to imagine
that many early humans lost their lives because they couldnt sit quietly
and count their breaths for forty-five minutes. Its much more likely that
the problem solvers, not the breath noticers, survived.
So here we sit, at the tip of an evolutionary branch with our fellows,
ready to find and solve any and every problem that exists now, existed
in the past, or might exist in the future. This capacity has allowed us
to outstrip every species on the planet in terms of our ability to spread
across the face of the earth (and even off of it). But this marvelous capacity hasnt come without a cost.
The great success of human problem solving has a dark side. The
cost is that problem finding and problem solving get extended into areas
where they interfere with valued living. The irony is that, even there,
they appear to be in the service of valued living. The problem with problems is that when were in the midst of problem solving, the rest of the
world disappears for us. It makes sense that problems would dominate
our awareness in this way.
Returning again to the savanna, imagine our early hominid lying
out on the grass on a sunny day with a belly full of food. She feels the
13

Mindfulness for Two

soft grass pressing into her back, looks up at the clear blue sky, smells the
sweet spring day, and feels the warmth of the sun on her face. Suddenly
she hears the roar of a lion. What happens to her awareness of the grass,
the scents in the air, the blue of the sky, the warmth of the sun? Gone. In
that instant, everything vanishes from her awareness except the lion and
the best way to make it safely to a nearby hole in the rocks that is just too
small to accommodate a lion. The lion and the hidey-hole are the only
things that matter in that particular moment.
The trouble for us humans is that things like self-doubt, anxiety
about failure, and concern about acceptancewhich feel every bit as
threatening to us as lions, tigers, or bearsare, in fact, very different in
kind from these threatening beasts. What happens if you linger with a
lion? You get eaten. But what happens, though, if you linger with depression, anxiety, or self-doubt? And what happens if you linger with a client
that presents these same things? You might be tempted to say, Id get
eaten metaphorically. Id be pulled in, and it would get worse. But I
think youd agree that there is significant difference, in kind, between
being eaten figuratively and eaten in fact. I think you can see where Im
heading.
What if problem solving twenty-four hours a day, seven days a week
werent the best way to live? What if problem solving twenty-four hours a
day, seven days a week werent even the best way to problem solve?

ON MATH PROBLEMS AND SUNSETS


For therapists, our clients often appear to us as problems to be solved.
This is especially true with our most difficult clients. I frequently do
consultations on difficult cases. (Funny, people never call me about
their easy cases.) When consulting on difficult casesclients who are
suicidal, clients who dont improve in spite the best efforts, clients who
keep coming back to the same issue again and again and againI often
ask therapists, Is your client a sunset or a math problem? The usual
response is a puzzled look.
I asked whether your client is a math problem or a sunset?
Huh? the therapist puzzles.
Whats two plus two?
The therapist stares at me.
This isnt a trick question: Whats two plus two?
He gives in. Four.
Right, I say. And what is three times five?
14

Coming Face-to-Face with the Human Condition

Fifteen.
Right again. And so, what do you do with a math problem? You
solve it. Or, maybe if its a hard math problem, you struggle for a while
first. And if its a really, really hard problem, maybe you struggle for a
while and then give up or you ask someone else to help you solve it. But
what do you do with a sunset?
The therapist pauses. You look at it?
Right, I reply. And if its a really gorgeous sunset, perhaps you
stop, rest a moment, notice the variation in color, the way it plays off the
clouds. You appreciate it. Do you ever try to solve a sunset?
No, the therapist replies.
Okay. So when you sit in the room with this client, whats it like to
be with her? Is she more like a problem to be solved or like a sunset to
be appreciated?
Yes, now I get your point.
Have you ever been a problem to be solved? I ask. Maybe in school?
Maybe at home with your parents? Or with your spouse or at work? Have
you ever been someones problem? What was that like? Whats it like to
be a problem to be solved?
Not fun, the therapist concedes.
And how about the way your client sees herself? Is she a sunset to be
appreciated or a problem to be solved?
All of this isnt to belittle attention to problems or to diminish in
any way the extraordinary problems our clients often bring to therapy.
Do our clients have problems? Sure. Are our clients problems? Sure. Are
they merely problems? No. Its simply the case that the problems get our
attention and tend to diminish our attention, awareness, and, perhaps
most importantly, appreciation of the whole human who is sitting in
front of us.
There is another side to this coin. Whats it like to be appreciated?

EXERCISE: Appreciation
I would ask you to think back in life to times when you were appreciated
by someone. Maybe it was a parent. Maybe you had a teacher who took
a special interest in you. Close your eyes a moment and see if you can
visualize that person or recall what it was like to sit with her. Linger,
for a moment, with what it meant to you to be noticed, seen, admired,
appreciated.
15

Mindfulness for Two

As we move along in the book, Ill introduce exercises and ways


of being with clients that contain a good bit of simple appreciation.
Understand, though, that Im not suggesting that appreciation alone is
sufficient. But I do feel that theres good reason to believe that appreciation is a place from which important work can be done.

LIBERATION: THE OTHER GREAT FACT


OF HUMAN SUFFERING
The one great fact of human suffering is that it lies all about us. Were
capable of suffering under just about any condition. In the poem Dover
Beach, we hear the words of the newlywed listening to the waves break
on the sea coast:
Ah, love, let us be true
To one another! for the world, which seems
To lie before us like a land of dreams,
So various, so beautiful, so new,
Hath really neither joy, nor love, nor light,
Nor certitude, nor peace, nor help for pain;
And we are here as on a darkling plain.
Matthew Arnold, Dover Beach (1998, 7879)
We might imagine his wife abed and Matthew at the window, contemplating the darkness and futility of the world. Frustrated with his
poetic melancholy, mightnt Mrs. Arnold say, Just come to bed, dear?
It appears to be possible for humans to suffer under any and all conditions. However, there is a complement to the extraordinary capacity of
humans to suffer, and thats our capacity for liberation. A prototypical
example can be found in Victor Frankls landmark book Mans Search for
Meaning (2000). In the book, Frankl describes his experience in the Nazi
death camps during World War II. He speaks at length about suffering
in the camps, which is no surprise. However, the point upon which the
entire book turns is Frankls description of the time he and a companion
find a way to escape the camp. They gather some food and a few other
supplies. The day before their planned escape, Frankl decides to make
one last round with the patients in his makeshift hospital. He knows that
his medical efforts are largely futile. The prisoners under his care are
16

Coming Face-to-Face with the Human Condition

dying of malnutrition, dysentery, and untold other causes. He has little


to offer them except comfort.
Frankl describes one fellow he had been particularly keen on saving,
but who was clearly dying. On Frankls last round, the man looks into his
eyes and says, You, too, are getting out?
Frankl writes, I decided to take fate into my own hands for once.
He tells his friend that he will stay in the camp and care for his patients.
Upon returning to sit with his patients, Frankl describes a sense of peace
unlike any he had ever experienced.
I would contend that Frankl was freed that day in the camp. Even
though his outward circumstances were some of the cruelest fetters
devised by human beings, Frankl was able to experience freedom. What
this means to me in my work with clients is that no matter what circumstance theyve suffered, no matter what hardship or loss theyve endured,
its possible for them to experience freedom and dignity. I hear Frankl
give voice to it, and Ive seen it with my own eyes. One great fact of
human suffering is that its pervasive; the other great fact is that liberation is at hand.
By this, I dont mean liberation from pain. I dont mean and they
lived happily ever after. I mean that I assume every client who walks
through my door is capable of experiencing a sense of meaning and
purpose in her lifethat she is capable of having a life that she could
say yes to, independent of the pain it brings. I also dont mean that this is
likely. Im not interested in probabilities as much as Im interested in possibilities. I care less about whats likely to happen and more about what
could happen. This may appear naive. In a certain sense it is, but its not a
naivety born of ignoring or denying what is likely. Its naivety chosena
sense of wonder chosen in the service of those who ask for my help.
Why? Well, sometimes very, very improbable things happen. In the
early 1970s, if you had asked me how apartheid would end in South
Africa, I would have bet that it would end with blood running in the
streets. I was wrong. My suspicion is that when Gandhi suggested that
the British could be compelled to give up their colonial interest in India
without force of arms by simple, passive resistance, people thought he
was nuts. And they too were wrong.
I had a client fifteen years ago who participated in an HIV-positive
substance abuse support group. She came to me after living for more
than a decade on the streets of San Francisco as a street prostitute, thief,
and heroin addict. Shed lost a couple of children permanently to child
protective services because she couldnt care for them. This was about
17

Mindfulness for Two

1990, so the survival prospects for AIDS were poor. Virtually everyone
in the group had watched a host of friends waste away and die. We had
AZT, but none of the newer, more effective antiretroviral drugs had been
developed.
In that very first session, I could see in her a longing for something.
I could see someone who, long ago, had imagined something better for
herselfsome ambiguous more. That more had not appeared, but the
spark of the longing survived. Humans are amazing.
I was moved to respond to that longing. I told her that if she wanted,
I could help her find a place in Reno where she could hunker down,
learn to take care of herself, and live out her time with some comfort.
The fight against AIDS was in its early days. People were terrified of
the disease. Even people who knew better would stiffen a bit when they
hugged someone with AIDS. The people in that group could feel it.
I told her that there was another thing she could do. In a war, the
first soldiers who step up out of the trenches are all killed in a hail of
bulletsevery single one. And in the next wave, more of the same.
Certain death follows for the soldiers in the wave after that. But perhaps
in the next, a soldier or two make a few steps forward, and after that, a
few more soldiers make it. And, if they keep coming and coming and
coming, eventually they make it across that field of fire.
I told her that day, with tears in my eyes, that I wished it were not
so, but that in the fight against AIDS we were seeing that very first line
of soldiers step up from the trenches. They would all fall. If she wanted,
she could do that. She could step from the trenches and give voice to the
plight of people suffering with her illness. There was a spark in her eyes,
and she picked that banner up.
Frontline soldiers, she said.
She lived for a few more years. She got clean and stayed clean. She
worked in substance-abuse treatment facilities and traveled around the
region talking to women in treatment at community events. She sometimes scared the hell out of people who took her around. Her language
was coarser than youd expect from a public speaker. But her message to
women was one of hope and love and compassion.
You can stop. Its okay. You dont have to live that way anymore.
And her message to the communities was a plea to care for the ill among
them.
When she died, there were maybe five hundred people at her memorial. We all benefited from the love shed brought to the world in those

18

Coming Face-to-Face with the Human Condition

five years. My clearest image of her toward the end of her life was from a
meeting we both attended. She was in wasting syndromethin, her hair
wispy, her skin gone transparent like a fine silk covering. I was there with
one of my daughters, who was an infant at the time. She asked to hold
the baby. I recall with such clarity the joy in her eyes as she looked down
into the eyes of my childone life ending, another beginning.
I felt then and feel blessed now to have known her. She didnt live
long, she didnt live without pain and struggle, but she lived well. She
wanted her life to be significant, to make a difference, and she chose to
not allow even death to be a barrier to that significance. She lives and
inspires still in the stories I and others whom she touched pass on. She
left behind a real and lasting legacy. If you ever have occasion to see that
great, sad AIDS quilt, she lives there too and reminds us all not to give
up on our fellows.
What is at the heart of this story? Sometimes, sometimes, very
unlikely things happen. How likely was that story? Not likely at all, yet it
happened. And whats possible from your most impossible clients?

WILSONS WAGER
Is it possible for something extraordinary, marvelous, to happen in the
lives of our most troubled clients? We dont know. But we get to bet with
our actions and with the posture we take with our clients. Blaise Pascal,
a mathematician and philosopher of the seventeenth century, proposed
a stake known as Pascals wager. This gambit examines the outcomes
of assuming and not assuming the existence of God using a two-by-two
contingency table. Ive always thought of this as the logicians approach
to faith. In philosophy, it is known as the argument from dominating
expectations. In a nutshell, Pascal proposed that, in the absence of a
way to verify the divine through reason, we still ought to live as if God
existed. If there is a God, and we live our lives as if there were so, we
gain infinite reward in heaven. If there isnt, were none the worse for our
pains. If we choose to live as if there is no God and were right, theres no
problem. But if were wrong, we suffer infinite loss. (Pascal didnt actually
describe the details of perdition, figuring that loss of infinite gain would
prove his point. But you can almost smell the sulfur.)

19

Mindfulness for Two

PASCALS WAGER
God exists.

God doesnt exist.

Live as if God exists.

Infinite gain

No difference

Live as if God
doesnt exist.

The loss of infinite


gain

No difference

Never having been accused of excessive modesty, I thought that if


Pascal can dabble in oddsmaking, why not me? So I offer Wilsons wager.
Imagine that in the columns below we have the state of the universe.
Imagine that its at least remotely possible that for any given client, something extraordinary could happen in his life. Here I dont mean extraordinary on my terms but rather on his, the clients, terms. Extraordinary
might look very, very different for different clients. Extraordinary might
mean finding meaningful work, reconciling with a child, or, like my
client above, serving her fellows. In the rows, to the left, are our assumptions. We can assume that something extraordinary could happen, or
not. What follows then, is to work through the quadrants of the contingency table.

WILSONS WAGER
Something
extraordinary could
happen.
Assume yes

Assume no

Something
extraordinary could
not happen.

You and your client get to You feel bad and your
experience richness.
client feels bad.
Your client gets
sold short.

You get to feel good


about being right about
what a hopeless case your
client was.

Beginning with the upper right quadrant, imagine that, at the end of
days, you can tap some omniscient power and learn with certainty that
this client never had the chance to experience richness and beauty in his
20

Coming Face-to-Face with the Human Condition

life, yet in life you assumed something was possible and worked as if it
were so. Theres a cost that both you and your client paid. You peered out
into the future, longing for something marvelous that never came. You
and your client feel saddened by that loss. Thats a real cost.
Focus now on the lower right quadrant. This time the extraordinary
was impossible and you assumed so all along. Aha! I was right, you cry.
He really was a hopeless case! You get to feel good about being right. It
seems a small prize.
Now look to the bottom left quadrant, where you assumed your
client was hopeless but you were wrong. Against all odds, he could have
experienced something transformational and extraordinary. Instead, you
assumed the least and coached him to accept and pursue some minimal
existence. You sold him short.
And, finally, consider the upper left quadrant. You held out hope
that, against all odds, there was some spark of life, some unrealized possibility available to your client. You and he doggedly sought it out, wondered about its shape. You taught him to wonder, to dream, to feel for a
life that was significant for him. And, this time, you were right. That day,
you get to see things like I saw them with the client in my story and all
the others with variations on that story.
There are four outcomes in Wilsons wager, but only two ways to
bet. You either bet yes or you bet no. There are two mistakes possible in
Wilsons wager. One mistake is betting the client can have something
extraordinary and being wrong, and the cost is feeling bad. The other
mistake is betting the client cannot experience something extraordinary
and being wrong. The cost in that quadrant is selling the client short. So
you have to decide which kind of mistake youre willing to make.
You need to enter into Wilsons wager with open eyes. In contrast
to Pascals, my wager does have inevitable and painful consequences if
you bet yes and youre wrong. If you bet yes, with me, youll bury clients.
Theyll storm out the door and come to bad ends. Youll have to watch
them slip away, despite every ounce of your very best efforts. All of those
outcomes will bring you pain and self-doubt.
Yet the consequences of the other option, I think, are too horrific to
even contemplate, no matter what pain it might let us ignore. I assume
that its my job to bet yes on every single client who walks through my
door. No matter what. I assume that theres a way for my clients to live
their values under any and all circumstances. I assume that if Victor
Frankl could live his values and experience liberation in a death camp,
my clients, no matter what their history or circumstance, have that same
richness available to them.
21

Mindfulness for Two

SUMMING UP
So, pausing a moment, lets reflect on where weve come from. I claim,
along with many before me, that suffering is part of life. Im claiming that
its in the human condition to suffer and that were capable of suffering
under any and all conditions. I claim also that its in the human condition to resist suffering and that resisting psychological suffering has a
cost. Im claiming that the resistance is pathogenic and exacts a cost in
experienced vitality and fullness of life. Further, Im claiming that liberation is possible, that its possible for our clients (and for us) to experience
richness, beauty, and a sense of purpose under any and all conditions.
So what?
Well, if youre with me so far, it now falls to us to figure out how to
best act out our yes bet in the therapy room. Im arguing that this starts
with getting our clients and ourselves to fully show up in the therapy
room. In the next chapter, Ill start laying the foundation for an approach
to psychotherapy that I think makes this possiblean approach that
gives us the chance to really foster mindfulness for two. What follows in
chapter 2, as well as in chapters 3 and 4, is somewhat theoretical. Just so
you know, though, I will get to the practical stuff. Chapters 5 and 6 detail
practical ways to promote mindfulness in the therapy room, chapter 7
develops a new means of case conceptualization, and chapter 8 goes over
three major exercises that I think get to the very core of this work. But
first, in chapter 2, I want to go over some of the basic behavioral foundations of what Im proposing, and then, in chapters 3 and 4, I want to
situate mindfulness for two within the context of ACT.
Im grateful for your patience. I hope it will be well requited.

22

Chapter 2

A Clinicians Guide to
Stimulus Control

I often introduce myself by saying, in a hushed tone appropriate to a


confessional, My name is Kelly, and Im a behavior analyst. I typically
follow by asking whomever Im speaking to not to hold that fact against
me. Given the work I doespecially the frequency with which I throw
around words like heart, suffering, and liberationmany people are often
puzzled by my claim to be a behaviorist. But I find that this is because the
core characteristics of the behaviorism to which I adherecontemporary
contextual behaviorism in the tradition of radical behaviorismare confusing and obscure to a lot of people. (Dont worry if contextual behaviorism is unfamiliar to you. Well touch on it a little later.) Many of the folks
I encounter have very firm convictions about the value of behaviorism.
Yet they have a far less firm idea of what behaviorism actually is. My hope
is to shift this trend, at least somewhat, with this chapter.
Brace yourself. This chapter is going to be technical, more so than
any that follow it. And the terminology is going to be heavy. I cant really
get around this. My hope, though, is that by becoming more familiar
with the basics of stimulus control, your ability to detect subtle shifts in
stimulus control in the therapy roomwhether in yourself or in your
clientswill help you connect more deeply and intimately with your
clients, building a strong foundation for mindfulness for two.
ACT is the application of contemporary contextual behavioral psychology, a study of behavior focusing on context and function rather

Mindfulness for Two

than form, as it emerged from the tradition of radical behaviorism. In


an important sense, ACT is really applied behavior analysis, which is
the empirical observation of behavior with the goal of predicting and
influencing it. For many years, we didnt call it thatfor some rather
compelling reasons. Until recently, if you brought up applied behavior
analysis in a group of professionals, most of them would say, sometimes
out loud, sometimes to themselves, one of two things: Oh, I know about
that already, and I hate it, so I dont need to listen anymore. Or, on the
other hand, Oh, I know about that already, and I like it, so I dont need
to listen anymore.
Id like convince you that there is something important to listen to
in applied behavior analysis, whichever side you fall on. If youre inclined
to view behavior analysis as too narrow, mechanistic, and reductionistic,
I ask that you keep an open mind. There are a lot of behaviorisms out
there, and I think youll find that this one may leave out the elements to
which you object. If you have a positive view of behavior analysisor,
even, are a behavior analyst yourselfI would request that you join me to
look anew at some domains that maybe have gone unexplored or where
we, as behavior analysts, drew premature conclusions that satisfied us at
the time but failed to exhaust the possibilities of the theoretical model. If
you take the time to engage with this material, I promise that it will have
a positive impact on the work you do in the service of your clients.

NOT THE BEHAVIORISM YOU THINK


YOU KNOW
Behaviorism often turns therapists off because it hasnt particularly been
known for its contributions to psychotherapy. When many of us think
of behaviorism, we conjure up images of rats pressing levers. When we
think of radical behaviorism, we imagine all of the limiting, negative
things we think we know about behaviorismand then we radicalize
them, making behaviorism seem even more objectionable. In fact, radical
behaviorism, developed by B. F. Skinner, is the philosophy that forms the
basis for modern behavior analysis. Though perhaps radical behaviorism
was unfortunately named, its far from limiting.
When I encounter people who dont like behaviorism, I sometimes
ask them why. The most common misconception is that behaviorism
denies thinking and feeling. And the second is the notion that behaviorism shrinks human behavior down to an atomistic account of punishment
24

A Clinicians Guide to Stimulus Control

and rewards, a reductionistic process that eventually mechanizes rich


and varied human experience, turning us all into robots. If these caricatures are true anywhere in behaviorismand this is arguabletheyre
not found in the behaviorism of B. F. Skinner, and theyre certainly out of
place in the contemporary contextual behavioral account Im describing
in this book.

THINKING-FEELING BEHAVIORISM
All of us have a fraction of the world to which only we have direct access.
Others may see what we do with our hands and feet quite directly, yet
they dont have such direct access to our private events, that is, what
we think, feel, imagine, and desire. Any psychology that doesnt address
these matters is likely to be, and probably ought to be, rejected out of
hand. But this issue of whether private events are a proper subject of
study has been the frequent point of contention in the history of psychology. In the middle of the last century, empirical psychologyin its search
for a so-called objective psychologyran away from questions about this
world inside the skin.
In a symposium in 1945, the famous historian of experimental psychology Edwin Boring stated, Science does not consider private data.
Responding to Boring, B. F. Skinner quipped, Just where this leaves
my contribution to the symposium I do not like to reflect The irony
is that while Boring must confine himself to an account of my external behavior, I am still interested in what might be called Boring-fromwithin (Skinner, 1972, 384). Skinner never disavowed interest in private
events, but his was only one voice among many in behaviorism. And
many within the broader behavioral movement did call out for an analysis that dismissed our inner lifeor at least placed it outside the range
of science. Its very possible that a good deal of the contemporary rejection of behavior analysis has been in reaction to this rigidity, to positions that were held too stridently, to versions of behavioral psychology
that truly failed to take human cognition seriously. But, as even Hamlet
remarks, There is nothing either good or bad, but thinking makes it
so (Hamlet 2.2.250251). Commonsense observation alone suggests that
the human capacity for cognition exerts a considerable influence on our
behavior. Its not so far-fetched to imagine that, by neglecting to provide
a workable explanation of the role of private events within the framework of behaviorism, the mainstream of this tradition fell into disuse
during the ascendancy of cognitive psychology in the latter part of the
25

Mindfulness for Two

twentieth century. Regardless of the reason, the plain fact is that we now
find ourselves

at a point in time where manyif not mostindividuals


providing mental health care are not well trained in behavior analysis.

WHY DO WE NEED BEHAVIOR ANALYSIS?


So what? What difference would it make if none of todays clinicians
were trained in behavior analysis? It might not make much difference at
all but for the fact that contemporary psychotherapy took a turn in the
1990s, the new behavior therapies (of which ACT is one) emerged into
the profession, and clinical research started to suggest that this work
showed promise. With encouraging research findings came interest, and
as interest grew, more clinicians wanted to take advantage of these new
and promising technologies. And several of these new therapies formulate case conceptualization from a behavioral perspective. The glasshalf-full view here is that, if youre interested in these new therapies, an
understanding of behavior analysis is a genuine asset for you. But if youre
partial to a more pessimistic worldview, you might say that, without a
solid foundation in behavior analysis, youll have some serious holes in
your understanding and application of these technologies. And if you
do, youre certainly not alone. Basic behavioral training all but vanished
from clinical psychology curricula in the last couple decades of the twentieth century.

RETHINKING BEHAVIORAL TRAINING


So we have several generations of clinical professionals that may lack
a strong foundation in basic behavior science, and we have a number
of emerging modalities that depend on theses skills for successful case
conceptualization. What can we do about that?
There are several different approaches to basic behavioral training.
Some are highly technical and make use of the hugely precise language
and razor-fine discriminations that are necessary for basic laboratory
work. Yet while these technical details are important in research, some
are less so outside the laboratory. Im going to go out on a limb and
guess that youve not made notes about a changeover delay in a concurrent VI-2' /VI-2' schedule of reinforcement on any of your clients charts
lately. What would be of great benefit to you, especially if you are drawn
26

A Clinicians Guide to Stimulus Control

to the new behavior therapies, is an understanding the core of behavior


analysis: the functional relation between behavior and the contexts in
which it occurs.
This is what Ill be guiding you through in this chapter. I want to
introduce behavioral thinking in a way that I hope is useful for you if
your behavioral training happened a long time ago, was maybe less rigorous than you might now wish, or was not well integrated with clinical
work. And, of course, this chapter should be of considerable value to you
if youve had no behavioral training at all. Along the way, Ill give you the
barest outline of a contextual behavioral perspective from which you can
observe your clients activities (and your own).
As someone trained at depth in both basic behavior analysis and
clinical psychology, I think that basic behavior analysis has an important
message for applied psychology (of which clinical work is a subset). In what
follows, Ive struck a balance between applicability to clinical work on one
hand and technical accuracy and completeness on the other. The material
here is directly relevant to both understanding and doing ACT. As we go,
well connect technical explanations with clinical examples. By doing this,
I hope both to keep these technical distinctions relevant to your practice
and to prevent you from lapsing into a technical analysis coma.

BEHAVIOR ANALYSIS: GETTING STARTED


The foundation upon which behavior analysis rests is the relatively
uncontroversial idea that behavior is influenced by the context in which
it is embedded. In a certain sense, behavior analysis can be thought of as
a relatively refined language that enables us to talk about behavior and
the contexts that influence it. It is, in a real sense, contextual behavioral
psychology.
Contextual behavioral psychology serves a practical purpose: it helps
us make sense of the world around us. As with other scientific perspectivesphysics, geology, biologywe (humankind) adopted it because
we found it useful to organize the world and its events into categories and
into the relations among categories. But make no mistake: the categories
and relations youll encounter in the following pages are not true in the
capital T sense of true or, by any means, exhaustive of all human behavior. They serve a practical purposeto enable us to have the discussion
that is behavior analysisand we can and should let them go when they
no longer serve us well.
27

Mindfulness for Two

Behavior analysis is nothing more than a way of speaking about what


people do. There are innumerable ways of speaking about what people do,
including other scientific ways of speaking like those I mentioned above.
In addition to these, there are countless nonscientific ways of speaking
poetry, theology, just plain old common sense. Behavioral ways of speaking
ought not be measured against other ways of speaking. Rather, behavior
analysis ought to be measured against the ways such speaking can be useful
in meeting our goals. In short, when evaluating our use of behavior analysis, or this way of speaking and categorizing, we need to ask ourselves to
what extent our analysis helps us in understanding the behavior of clients
such that they become free to move their lives in a valued direction.

THE DISTINCTION BETWEEN BEHAVIOR


AND CONTEXT
Behavior analysis is a precise yet general way of speaking about behavior,
the context in which it occurs, and the relations between behavior and
context. Since the elements of our analysis will be aspects of behavior
and context, its very useful to distinguish between the two.

Behavior
There are widely divergent views in psychology regarding what is
meant by behavior. My own first encounter with behavior was in developing and implementing behavior plans for individuals with developmental disabilities. I was taught in most of my introductory psychology
courses that behaviorism confined itself to publicly observable responses
walking, talking, speaking, and the like. My very first course on behavior
analysis was taught by Sam Leigland, an early mentor of mine who still
teaches at Gonzaga University. Sam is a tall fellow of Scandinavian descent
who can turn his entire body into a question mark. So, on the first day of
class, this tall Scandinavian question mark turned to us and asked, What
is the subject matter of behavior analysis? He didnt wait for an answer. He
supplied one emphatically: The subject matter of behavior analysis is any
and all of the activities of the integrated organism! Any and all!
At the time, I was carrying a copy of Mans Search for Meaning
around in my pocket as a sort of compass. I went to Sams office after
that class and asked him, What about this? Can behavior analysis help
28

A Clinicians Guide to Stimulus Control

us to understand what happened to Frankl in that death camp? Can it


help us to understand the human capacity to find meaning in the midst
of horror?
Sam didnt give me an answer that day. Instead he gave me a job.
The essence of what Sam told me was that if behavior analysis could
not make sense of the most profound human activities, then it is not
worth much. Sam got me reading papers like Radical Behaviorism in
Reconciliation with Phenomenology (Day, 1992) and Making Sense of
Spirituality (Hayes, 1984). He showed me that there was a richness in
behavior analysis that was nowhere to be seen in introductory psychology texts. (As I write this, Im reminded what a great gift my best teachers have been to me.)
Often behavior is distinguished from things like thinking and feeling.
The behaviorism Sam offered to me, and that I in turn offer to you,
says that if an organism can do it, it is behavior. Could a person think,
imagine, believe, hope, want, freak out, or feel exuberant, despondent,
inspired? Or, like Frankl, could a person find meaning in the midst of a
death camp? If the answer is yes, then that is behavior from this perspective, and is an entirely proper subject matter for our science. Behavior is
what is to be explained.
For our purposes, behavior will be considered an ongoing, evolving stream of activity in dynamic interaction with context. Behavior, so
defined, is the dependent variable of our analysis. We will seek the ways
in which it depends on, or is organized by, context.

Context
Just as behavior is anything that an organism can do, context is
anything that can happen to an organism. This includes both what is
currently happening and also what has happened to the organism all
the way back to the beginning of its existence. From this perspective,
context is anything outside of the behavior being analyzed that influences the development, expression, modification, or maintenance of that
behavior, including both current and historical context.
Context, or some aspect of context, is the independent variable in
our analysis. If we want to have an influence on our clients behavior,
we will need to understand that which influences behavior. We could
suppose that behavior just changes on its own or that change will come
spontaneously from the client, but if that is all there is to it, what is our
job as therapists?
29

Mindfulness for Two

The issue of influencing client behavior has been a sticking point for
behavior analysis. Perhaps it sounds manipulative. Sam had a response
to that too. He asked me what I wanted to do for people. I told him that
I wanted to help them to find meaning.
How? he asked. What will you do? In that simple question, Sam
was leading me back from clients behavior (meaning making) out into
their environment (their interaction with me and the world around
them). What will you do? is a practical question.
This is useful because we are an important part of our clients environment. Anything we do to influence our clients behavior is done
from outside that behavior. We change both the immediate context
of a behavior to give clients the opportunity to do something different
and, through a series of interactions, change the historical context of a
pattern of behavior. The context in which the behavior occurs is your
point of impact as a therapist. Context, then, is that which lies outside
behavior, and which exerts an organizing influence on the behavior
being analyzed.

Context and Behavior


Imagine a client comes into your office. He says to you, I want to
die. Every day I get up and I wondercan I do one more day? And, if I
can, how many more can I do after that?
There are a lot of ways you could respond to a statement like that.
How might it influence that ongoing stream of your clients behavior if
you threatened hospitalization, if you appeared distraught and frantic
when you heard your clients words, or if your response suggested that
your first concern was to avoid liability with respect to your client? And
how might it influence your client if you seemed genuinely interested in
hearing the heart of his despair? Depending on your clients history, any
of these different responses might produce dramatically different effects
on how he responds to you and what actions he chooses to take, if any,
because of your encounter. Your client might become angry. He might
jump out of the window. He might be calmedor might feign calm.
I mean nothing controversial when I claim that context organizes
behavior. Your client behaves, and you respond. Your response is the
context for your clients behavior, and it has an influence. The same analysis could, of course, be made of your behavior. Your clients behavior is
the context in which you yourself behave. Sometimes its useful for us to
focus on the way in which context impacts your behavior as a therapist,
30

A Clinicians Guide to Stimulus Control

but for now, lets stay focused on your clients behavior. Even when we do
look at your behavior, well want to start our analysis with one stream of
behavior at a time. Its simpler and more likely to be useful to do so.

Responses and Stimuli


Another way of speaking about the behavior-context distinction is in
terms of responses and stimuli. Responses are behavior, or what an organism does, and stimuli make up context, or what happens to an organism.
For example, if we hear a phone ring, hearing is the response, and the
ringing is the stimulus. This language highlights the practical nature of
the context: we distinguish here between stimulus and response only to
facilitate our discussion of what is actually a singular event, in this case,
hearing the phone. A stimulus is not a stimulus apart from that which it
is stimulating, and a response is not a response apart from that to which
it is responding. There is no stimulating without responding and no
responding without stimulating. Responding and stimulating are a functional unit. So, in this case, there is no hearing (behavior) independent
of what is heard, and no what is heard (context) apart from hearing.
Thus well consider any behavior that we want to analyze in and
with the context. Any part of any event that seems important in our
project of prediction and influence will belong either on the behavior
side of the equation (a response) or on the context side of the equation
(a stimulus). Those on the behavior side are the events that we seek to
influence, while those on the context side are the events that do the
influencing. If, considering the example above, we wanted to determine
how soon someone is likely to answer the phone when it rings and get
her to answer more quickly (predict and influence behavior), we would
consider the volume of the ringer, the subjects proximity to the phone,
whether she is wearing earmuffs, and so forth (the context in which the
behavior takes place).

Two Common Errors in Understanding Responses


and Stimuli
Two common misconceptions about responses and stimuli are
that responses are movements and stimuli are discrete objects. From a
contextual behavioral perspective, these are both incorrect in the most
31

Mindfulness for Two

technical
sense. On the response side, standing still is defined as a
response if I can demonstrate that standing still, as the response of interest, is capable of being organized by context, which is to say, capable of
being provoked by some kind of stimulus. For example, if I give you a
five-dollar bill when you stand still and take five dollars when you move
and thereby alter the probability that youll stand still, then standing
still meets our definition of behavior: its something the organism can
do. Also, standing still can be brought under contextual controlthat
is, its in dynamic interaction with a stimulating environment.
On the stimulus side, the most common error is to think of a stimulus as an object. We might, for example, see the five-dollar bill as the
stimulus that organizes behavior. In a limited sense, this is true, but a
more sophisticated way to think of this is that standing still changes the
world from one where you cant buy things to one in which, with your
crisp, new fiver, you can. It is that transition from not having the power
to buy things to having that power that organizes behavior, not the bill
per se. For example, if I gave you a billion dollars, the promise of an extra
five bucks would likely no longer organize your behavior, and you would
stand still or move as it pleased you. Or if I locked you in a cell where
money couldnt be spent or given away, five dollars (or even a billion)
wouldnt do much to organize your behavior. Why not? Because receiving the five-dollar bill in either of those two contexts wouldnt change
your world in any significant way.
In many applications, calling the five-dollar bill a reinforcer of
behavior is probably workable. (We should remember that, despite the
leaps and bounds of contemporary physics, Newtons classical mechanics
work just fine in most instances too.) However, we want a more sophisticated understanding of the dynamic interaction of responding and
stimulating.
Why does it matter? The distinction matters because sometimes
theres no object or immediate discrete event to which we can point.
Richard Herrnstein and Philip Hineline (1966) carried out a classic
experimental example that illustrates this point nicely. In their study, rats
were placed in an experimental chamber, and the floor of the chamber
was briefly electrified at random intervals. If the rats pressed a certain
lever within the chamber, the shocks would come at a slightly increased,
though still random, interval. What Herrnstein and Hineline found in
the experiment was that lever pressing was maintained in the rats. We
cannot understand the maintenance of the lever pressing by appealing
to the immediate effects of lever pressing. The most common immediate
effect of a lever press was that nothing would happen. In fact, as result
32

A Clinicians Guide to Stimulus Control

of the shocks coming at random intervals, the lever press was sometimes
followed immediately by a shock. Why did the rats press the lever? In
simple terms, the rats pressed the lever because doing so precipitated a
transition in context from one in which shocks are more frequent to one
in which they are less frequent.

SEEING PATTERNS IN RESPONSE


AND CONTEXT
In clinical settings, the contextual events (the stimuli that organize
your clients behavior) will frequently not be nice discrete objects. Youll
seldom have the luxury of seeing an M&M dispensed in the therapy room
with the press of a lever. I sincerely hope that you wont see your clients
respond to intermittent electric shocks. What you will see, though, are
transitions in patterns of responding. And where you see the transition,
thats where youll look for organizing context.
What are we seeking as we listen to our clients stories? How do we
find the organizing context? In some respects, a behavior analysts job
is one of pattern recognition. Although I am interested in the content
of my clients responding, I am even more interested in the patterns of
responseincluding the patterning of contentand the patterns of the
contexts in which they are embedded. I have a particular interest in stereotypy, that is, in repeated patterns. These patterns can be quite fascinatingly complex and varied. Ask yourself these questions about your
clients responses:

Is there a particular pitch and pace to her responding?


Does he complain and complain?
Does she ruminate and ruminate?
Is the topic the same, over and over again?
What is the physical posture he assumes as he conveys his
story to me?

These are just a few possibilities of patterns. Its likely that your client
will exhibit several patterns. Can you recognize them? Could you characterize them in terms of pitch, pace, tone, and content? This is the task
we have at hand: to make useful observations about the behavior that
our clients bring into the room.
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Mindfulness for Two

Metaphorically speaking, the activity of observing behavior is like


listening to a bit of music. You might listen for the bass line and for a
moment let go of the lyrics and the flashier lead guitar. Can you listen
and let it move you? Tha-thump, tha-thump goes the bass guitar in the
background. Can you hear that patterning of response?
Once you hear that pattern, can you bring your attention to the
context side of the behavior-context interaction? The sound quality of
the hall, the ambient noise in the background, the shuffle and rustle
of the crowd? Can you listen for both behavior and context at the same
time? Focus on both the music and the room? Yes, of course, but remember that dividing your subject matter into behavior and context is a
pragmatic matter. Attending to one side of the interaction at a time is
simpler. As you get better at it, you can begin to see the ebb and flow of
interaction, but it is best to start with a simpler set of discriminations.
Two pieces of context are particularly relevant. First, whats going on
in the story the client is telling? What is the context in which the story
occurs? Is it a social context? Is it a context involving intimacy or potential intimacy? Is it a time when she is alone and has nothing to do? Is it
a context in which he is being evaluated by a supervisor, a parent, or an
acquaintance? And, second, when does this pattern come up in session?
What was your interaction with the client when this pattern emerged?
Are there certain topics that precipitate the clients behavioral pattern?
Do certain emotionally laden issues precipitate the pattern? Are there
things going on in your relationship with the client that seem to precipitate this behavioral pattern? What youre seeking are patterns of context
that are correlated with patterns of behavior.

WATCH FOR TRANSITIONS


If you think about behavior as being in dynamic interaction with
context, you can assume that when you see a transition in responding,
there has been a transition in context. With nonhuman species, this is
often obvious. The birds are chirping, and they suddenly stop. You look
around and see a cat sneaking up through the grass. The dog is lying
in its bed, then jumps up and runs to the window. Moments later you
hear a delivery truck pull into the driveway. The cat is sleeping on the
sofa. You begin to open a can with the electric can opener, and the cat
comes running. All of these are examples in which the transition in the
environment organizes a transition in behaviorand the transition in
34

A Clinicians Guide to Stimulus Control

environmentthe cat sneaking up, the delivery truck arriving, the can
opener whirringis quite obvious.
With humans, a transition is often not so obvious. You may sit and
listen to your client describe her week. At some point in the conversation,
you note a change in pace or tone. Suddenly she becomes very animated
or very anxious. Or perhaps youre asking about a clients visit to a friend
and see him become momentarily emotional. Why? Sometimes it may
be quite obvious what precipitated the transition, but sometimes it isnt
at all clear. As you delve more deeply into the ways context organizes
behavior, youll begin to see how you can look for particularly telling
transitions in behavior. Neither therapists nor clients are typically skilled
at detecting subtle shifts in context and the influence they exert over
behavior. However, such skill can be cultivated. Noticing such transitions in behavior can lead you to understanding what precipitated them
and to which interventions would be called for when you see them.

CONTEXT: ANTECEDENTS
AND CONSEQUENCES
Within the broad category of context, several distinctions can be made.
The simplest of these involves distinguishing whether the relevant stimulating context occurs before the behavior of interest (antecedent) or after
the behavior of interest (consequence).

Antecedent Stimulation
Some client behavior is under antecedent control. Antecedents are
stimuli that come before a response or pattern of responding that change
the likelihood that the response pattern will occur. For example, a
gunshot increases the likeliness that a startle response will follow. There
are other kinds of antecedents too. For example, if the phone rings, we
are likely to answer it. Both the gunshot and the ringing are antecedents, but as we shall see, there are important differences in the kinds of
behavior they precipitate. The gunshot has a sort of automatic effect on
behavior. Gunshotstartle. Gunshotstartle. We call this particular
kind of antecedent an eliciting stimulus. The ringing of the phone is different. If the phone rings, we will probably answer it but maybe not. If we
have a lot of other things to do, if a particularly good program is on the
35

Mindfulness for Two

television, or if the caller ID says blocked, we may not answer. We call


this sort of antecedent a discriminative stimulus.

Consequential Stimulation
Some client behavior is under consequential control. Consequences
are stimuli that follow a response and change the probability that the
response will occur again. Depending upon the effect on behavior, we
call these consequences reinforcers or punishers. Stimuli that follow a
response and increase the likelihood of a response are called reinforcers. For example, praise could be a reinforcer for a childs reading if it
increased the probability of reading. By contrast, stimuli that follow a
response that reduce the likelihood of a response are called punishers. A
painful burn could be a consequence that would reduce the likeliness of
touching a flame. These responses occur because the world changes in
some important way when they happen. When a man yells at home, his
wife and kids make no more demands on him. When a child cries, the
parents allow another hour of television. These examples illustrate ways
in which behaving (man yelling, child crying) changes the world, and
how that change or transition in context (no more demands, another
hour of television) influences the likelihood of that response happening
again.
Theres a link between consequences and antecedents. Sometimes
an antecedent, like the ringing of the phone, signals an available consequence. Discriminative stimuli and consequences go together. When the
phone rings and I answer it, there are consequences. My world changes
from one where I dont get to talk with you into one where I do get to
talk with you. This doesnt happen when I answer the phone when it isnt
ringing. It seems so unfair!

BEHAVIOR: RESPONDENT AND


OPERANT CONTROL
We can also look more closely at the behavior thats linked to antecedent
and consequential stimulation. (Stop and take a deep breath. I know this
is getting a little dense and theoretical, but I promise that Ill bring this
back to the therapy room and show you why its essential to understand
these distinctions. And breathe. Dont you feel better now?)
36

A Clinicians Guide to Stimulus Control

Like stimuli, responses can be divided into two major categories.


Some patterns of responding are primarily sensitive to antecedents.
Other patterns of responding are sensitive to both antecedents and
consequences.

Behavior Under Strong Antecedent Stimulus Control


Some responding is mostly sensitive to antecedents but relatively
insensitive to consequences. Remember that gunshot and the startle
response? What if I threatened to take one hundred dollars out of your
wallet if you were the least bit startled when the gun went off? The
gunshot would still produce a startle response. That startle response is
just not very sensitive to consequences. You might be able to restrain
it some. Its not perfectly fixed, but it is relatively insensitive to that
aspect of context we call consequences. Behavior of this sort has an
almost mechanical quality to it. If the stimulus happens, the response
happens with near 100 percent certainty. Depending on the stimulus,
if it is presented again and again in rapid succession, the response may
get smaller over time. However, generally speaking, a period of time
without the stimulus will restore the response to its original strength.
This sort of strong antecedent stimulus control is sometimes called
respondent stimulus control, and the behavior it controls is called respondent behavior.
Behavior under strong antecedent stimulus control can occur with
no learning history. This would be the case, for example, if you got
startled after hearing a loud noise. We call this unconditioned respondent
behavior or an unconditioned response (UCR), and the relevant stimulus
an unconditioned stimulus (UCS). However, such behavior can also be
learned. For example, if you were bitten by a dog, seeing a dog later
might produce strong arousal. If you were in a serious car accident,
you might become fearful of driving. Driving isnt innately fearsome,
but it may become so when its paired with something that is fearsome,
like an accident. Of course pleasurable things can also be conditioned.
Cases like all of these are sometimes called classical conditioning, and
the resulting behavior is called conditioned respondent behavior or a conditioned response (CR), and the relevant stimulus that was previously
neutral a conditioned stimulus (CS).
In addition, humans often become fearful even without any direct
experience of the feared object. For example, many people are afraid of
snakes, even without any direct painful experience with snakes. There
37

Mindfulness for Two

are documented cases of snake phobias where the individual has never
even seen an actual snake. Not only can humans become fearful of things
theyve never encountered, they can even become fearful of things that
dont exist: demons or monsters under the bed, for instance. If you think
about your difficult clients and the things that generate near-mechanical
reactions in them, the overwhelming majority of the events that precipitate these reactions are learned, not unlearned. They are conditioned
respondent behaviors. Some of these responses dont necessarily involve
very direct learning histories, but they are, nevertheless, learned and
therefore conditioned respondents.
Conditioned respondent behavior will be of particular interest to you
in your clinical work. It differs from unconditioned respondent behavior
in that it is much more malleable. If a person were to interact in a variety
of ways with a conditioned stimulus without the unconditioned stimulus,
the strong antecedent stimulus control would be reduced over time. For
example, if a tone were reliably followed by a shock, the tone would begin
to produce a stereotypical startle response. If the tone were presented
many times without the shock, the startle response would diminish. The
narrow patterning of behavior will be extinguished, leaving the stream
of behavior more sensitive to other aspects of context.

Responding Under Both Antecedent and


Consequential Control
Some responding is sensitive to both antecedents and consequences.
For example, if you bring the phone to your ear and get to converse with
someone you enjoy, you will be more likely to pick up the phone again
because doing so previously has resulted in an enjoyable conversation.
You do not, however, walk around with the phone held to your ear all
day. You wait for it to ring. The ring signals the availability of the enjoyable conversation, which makes putting the phone to your ear more likely
when the ring occurs. Holding the phone to your ear is sensitive both
to the antecedent ringing and to the consequential enjoyable conversation. The absence of either the antecedent or consequential conditions
is related to decreases in probability of the response. Remember, as we
discussed above, this sort of behavior typically has more flexibility and
more sensitivity to other conditions (youre busy, a movie is playing on
TV, and so forth). We call this sort behavior that is sensitive to both
antecedents and consequences operant behavior.
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A Clinicians Guide to Stimulus Control

AVERSIVES, APPETITIVES, AND ABUNDANCE


In addition to being distinguished in terms of whether they precede or
follow the behavior in question, antecedents and consequences can also
be distinguished in terms of their effects on behavior. Appetitive stimuli
are what we call stimuli that an organism will work to produce. Aversive
stimuli are those that an organism will work to stop, postpone, or attenuate. There are some critical differences between behavior under aversive
control and behavior under appetitive control. Understanding these differences can make you a better clinician.
Patterns of behavior under strong aversive control tend to be relatively narrow, relatively inflexible, and relatively insensitive to consequenceswith the exception of consequences that discontinue,
reduce, or postpone the aversive. If I shot a gun off in the room while
you were watching television, notice what would happen. First, youd
probably show a very strong startle response. That startle response is a
good example of strong antecedent stimulus control. Second, youd stop
doing just about everything else. For example, you might be noticing the
smell of dinner cooking, you might be shopping on the Internet on your
laptop, you might be sipping a cup of coffee. All of these responses would
stop immediately. Strong aversive stimuli have an overall suppressing
effect on the patterning of behavior. One exception to this suppression is
escape. In the presence of strong aversive stimuli, learned or unlearned,
behavioral patterns become relatively narrow, relatively inflexible, and
relatively insensitive to various aspects of context, except those aspects
of context that are related to the aversive itself and to escape.
So in the gunshot example, you might have shown considerable flexibility in your patterning of behavior before the shot as your attention
moved from the television to your laptop to smells emanating from the
kitchen, and so on. After the shot, all of those things would disappear
psychologically. The only things that would be psychologically present
would be the gunshot and the exit. An interesting program, a really great
bargain online, or the smell of the roast chicken being pulled from the
oven would have little influence over your behavior. All of your attention
would be focused on whichever exit was closest to you and furthest from
the gun-wielding maniac.
Just because aversive control tends to result in narrow behavioral
repertoires doesnt necessarily mean that all appetitive control results
in broad, flexible ones. In fact when deprivation is particularly high, as
with starvation, or where even minor deprivation is experienced as very
aversive, such as with drug dependenceit often results in the same
39

Mindfulness for Two

narrowness
of repertoire we find with aversive control. The greatest
breadth of behavioral repertoires tends to occur when behavior is under
the appetitive control of many sources of stimulation that the organism
will work to produceample food and security, an engaging environment, and so forth. Note, however, that abundance of reinforcement is
not defined independently of the behaving individual. Abundance is a
psychological factor, not one that can be defined by a physicist. A rich
social environment might seem to be a source of abundant reinforcement.
Even when people live among many others, though, they sometimes
experience themselves as being cut off, isolated, and alone.

RESPONDING UNDER MULTIPLE SOURCES


OF CONTROL
The distinction between responses mostly sensitive to antecedents and
those sensitive to both antecedents and consequences is purely functional. I dont intend to imply that these types of behavior actually exist
as separate entities. You are one organism. You have but one stream of
behavior, and there is a constant, evolving, dynamic interaction between
your pattern of responding and the context within which it is embedded.
Your behavior could at any given moment be sensibly described as being
under multiple sources of stimulus control. If we looked carefully, wed
likely find that all of your responses are under multiple sources of control,
influenced at least partially by both antecedents and consequences. It
is the ebb and flow of patterns of responding and patterns of stimulus
control that interests us.
I make these distinctions between different kinds of stimulus control
because different behaviors that your clients exhibit will show sensitivities and insensitivities, just like the ones Ive described. If your clients
behavior is under strong antecedent stimulus control and you warn her
about consequences or point out past consequences of engaging in that
behavior, its not likely to have much effect. Behavior under strong antecedent aversive control is like that, along with behavior under appetitive
control where deprivation is high. By definition, those patterns are not
sensitive to consequences (except possibly escape).
Also, its not the form of these behaviors that distinguishes them, but
rather their functional relationships with the different aspects of context.
A particular behavior could look the same on the outside, but could be,
in some conditions, under antecedent control and, in other conditions,
40

A Clinicians Guide to Stimulus Control

sensitive to both antecedents and consequences. For example, you might


stub your toe walking down a bumpy sidewalk and begin to cry because
of the pain. You may also get pulled over by a policeman and begin to cry
because, in the past, youve escaped a ticket by crying. Crying outside of
its context cannot be distinguished as either under antecedent or consequential control. With context, however, the distinction can be made. In
the first situation, crying is under antecedent control, and in the second,
it is under consequential control. At other times still, the same behavior
may be under both sources of control. Its less important to determine
if a behavior is an example of respondent or operant control and more
important to discern degrees of control and sensitivity. Likewise, you
cannot determine the meaning of client behaviors without looking to the
context in which those behaviors are exhibited.

PUTTING IT ALL TOGETHER


Most psychopathology shares some restriction in range of behavior. Those
with alcoholism may drink and drink; people with obsessive-compulsive
disorder may wash and wash; folks suffering from major depression may
stay in bed all day. The problem with alcoholism isnt drinking per se, its
having to drink. Its having to wash ones hands rather than hand washing
itself thats the problem with obsessive-compulsive disorder. And that
people with depression stay in bed all day with the covers pulled over
their heads is really a matter of little consequence in and of itself. Staying
in bed all day is delightful. I recommend it. Sometimes on vacation, I get
a nice fat novel and spend a day where I get up only to eat and go to the
bathroom. Ah!
No, once again, the problem isnt staying in bed. The problem is
having to stay in bed. The problem is the dread that overcomes the person
as he pulls the blankets off, drapes his legs over the side of the bed, and
lets his feet touch the floor. To just roll back into bed would give such
relief, with perhaps a promise to get up later. And in that moment, the
act of surrendering to depression buys a little peace.
Even with difficulties typified by erratic behavior, like the dramatic
cluster personality disorders, the thing that causes problems is that these
individuals are systematically erratic. Try to get a client suffering in these
ways to slow down a bit! Marsha Linehan, the founder of dialectical
behavior therapy (DBT), has spent her career developing technologies
that facilitate that process among just such clients. Setting aside the categories of problem behavior, there is a stereotypy (repeated pattern) that
41

Mindfulness for Two

cuts across categories. It may have many different forms, but the narrowness of the pattern is suggestive of behavior under strong antecedent
aversive control.
Take the example of a snake phobia. The defining features of a snake
phobia are arousal and avoidance in the presence of snakes. A typical
conceptualization of an exposure-based treatment is that as the phobic
individual begins to interact with snakes in a variety of different ways,
the probability of arousal and avoidance decreases.
This process can also be construed more broadly, considering the
range of responses that might be in the persons repertoire. People can
feed snakes, pet them, talk about them, study them, read about them,
watch them, and so on. With this in mind, snake phobia can be defined
not merely by the presence of arousal and avoidance but also by the narrowness and inflexibility of the range of behaviors in which the individual engages. Likewise, the effects of exposure would not merely involve a
decrease in arousal and avoidance but also an increase in the probability
of alternative responses.
With our clients, however, its not typically events that are intrinsically aversive, that create this narrowness and inflexibility. Rather, its
aspects of contextsuch as painful thoughts, feelings, memories, or
physical sensationsthat are experienced inside the skin. A client may,
for example, be interpersonally engaging and facile during sessions until
the memory of an abuse experience shows up. Suddenly that individual
begins to exhibit affective, verbal, physical, and attentional inflexibility,
just as if she had suffered an electric shock or other external aversive.
Some ACT interventions, such as values work, are about consequences. Specifically, they are about reinforcers. However, if the pattern
of behavior we see is under strong antecedent aversive control, talking
about values (that is, reinforcers) will have little effect. In fact, if the
person notices how his own behavior precipitates costs in some valued
domain, that too will be experienced as aversive, and narrow behavior
even more so.
If you can encourage this individual to sit quietly in the present
moment and to experience the difficult emotion with acceptance and
openness, then the strong antecedent stimulus control will lessen. As
it does, youll see the gradual emergence of flexibility in affect, speech
pattern, physical posture, and other aspects. Now, if you begin to gently
ask questions about valued living, those questions are much more likely
to be received in a more flexible and open way.
Being sensitive to the stimulus control being exerted can help to
direct your interventions so that they are responsive to the stream of
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A Clinicians Guide to Stimulus Control

behavior occurring in that moment. Youll need to cultivate a sensitivity


that stands in stark contrast to the rote execution of a series of interventions. Changing behavior under antecedent control requires different interventions than changing behavior that is under consequential
control. Those sources of stimulus control will come and go many times
over the course of a single session. Attention to both types of behavior
is necessary to help free up your clients to cultivate and pursue their
values.

STIMULUS CONTROL AND THE CLINICIAN


Having sufficient sensitivity to detect subtle shifts in stimulus control
can sound daunting. As is true elsewhere in the ACT model, the principles that apply to clients apply equally to clinicians. In fact, if you can
learn to detect the coming and going of aversive control inside your own
skin, youll be better able to detect and treat your clients with sensitivity.
In fact, your own reactions are the most sensitive instrument you have
in that room. Think about the last client you had who told you that she
wanted to kill herself. What happened to your repertoire when those
words came out of her mouth? Close your eyes for a moment right now
and notice what happens as you think about them. Can you feel your
chest tighten just a bit? Can you feel yourself wanting to move to the
next section? Thats what aversive control feels like. The time when your
behavior will most likely come under aversive control is when your clients behavior is under aversive control. It is a painful fact, but your own
experience is a sensitive instrument in making the discriminations Im
talking about. Generally, awareness of changes in stimulus control is a
clinical asset, and mindful awareness is a means of becoming more sensitive to these changes in control. So dont forget everything youve just
learned about stimulus control. It matters!
In the next chapter, well look more specifically at ACT processes
and see how these fit with this more basic technical analysis of behavior,
and well also take a look at mindfulness from an ACT perspective.

43

Chapter 3

The Hexaflex Model


and Mindfulness from an
ACT Perspective

ACT is currently thought of as the convergence of six core processes:


acceptance, defusion, self-as-context, values, committed action, and
contact with the present moment, which is quite central to mindfulness.
These six core processes are often represented graphically as a hexagon
(see the illustration near the end of this chapter) and have come to be
known collectively as the hexaflex model. Although they are described
individually, we misinterpret the theory if we think of these six processes
as independent of one another. Remember that ACT has functional contextualism at its theoretical core, which means that the organizational
structure of the six processes is of interest only to the extent that it serves
our purposes in a given context. The divisions we make in the process
model, an ostensibly unified event, are made for purely practical reasons.
Breaking the model up into manageable parts allows us talk about the
whole process picture in a manageable way. Yet, as well see, all of the
processes are entailed in all of the others.
In comparison, we might analyze running in terms of its speed,
rhythm, and biomechanics. But the running is still one thing. Speed,
rhythm, and biomechanics are ways of looking at the unified act of
running. In a certain sense, they are inseparable from one another.
Likewise the six ACT core processes ought to be thought of as analogous

Mindfulness for Two

to a gem cut into six facets. You could look into any of the six facets, but
what you would see in that facet would be the reflections of each of the
others.
In this chapter, well examine a stream of behavior by looking through
each of these facets or core processes. I dont make these distinctions
because these six are the fundamental atoms of behavior, but because
ACT holds that these are useful perspectives to take on behavior. The
basic distinctions we looked at in the previous chapter are like that too.
Theyre simply perspectives we can take on behavior, not the atoms of
behavior. We expect that there are many ways to view and understand
behavior that might be more useful for different purposes. Spiritual and
poetic understandings of behavior might, for example, be more useful
in some domains. The language used and the perspectives taken in this
chapter and in chapter 2 are intended to be useful for the development
of a science of behavior and for the orientation of practitioners. Beyond
those particular uses, I make no assertions about these distinctions.

ACCEPTANCE
Lets begin our examination of the six ACT processes from the hexa
flex with acceptance because acceptance is where the model began.
Acceptance processes involve taking an intentionally open, receptive,
nonjudgmental posture with respect to various aspects of experience. In
ACT, acceptance is typically spoken of in terms of experiential acceptance and its counterpart, experiential avoidance, which well look at
more closely below. The experiential reference in experiential avoidance is used to distinguish the nonacceptance of private events, such
as thoughts, from the nonacceptance of events in the external environment, such as an abusive relationship.
Experiential avoidance is not limited to cognitive avoidance. It also
includes other aspects of experience, such as bodily sensations, memories, thoughts, images, and behavioral predispositions. Behavioral predispositions are that cluster of thoughts, emotions, and urges that typically
precede some act. For example, drug addicts might experience a whole
array of thoughts, emotions, and bodily states and have a sense of inevitability that they will ultimately choose to take drugs. Similar experiences
can be found clinically in all of the impulse disorders, such as eating and
gambling, and in a lesser form in all of us as we gaze at the chocolate cake
and wonder whether we will have just one more slice. Of course, immediate relief from that discomfort is availablesimply take drugs, gamble, or
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The Hexaflex Model and Mindfulness from an ACT Perspective

eat. When such acts are done in the service of managing these difficult
experiences, we call that experiential avoidance.
In practice, acceptance of both internal and external events may
serve an individuals values. For example, Frankl accepted internment
in a Nazi death camp in the service of caring for his patients. It is often
the case that acceptance or change of external events can be served
by acceptance of internal events. Some research data may help support
this conclusion. For example, one study found that increased mindfulness on the part of parents produces more effective child management
skills (Singh et al., 2006). In addition, some workplace stress studies
have shown that employees receiving an acceptance-oriented intervention went on to show substantial improvements in workplace innovation
(Bond & Bunce, 2000; Bond & Flaxman, 2006).

Acceptance Isnt Approving, Wanting, or Liking


When were speaking to clients, its important to be clear what acceptance isand especially what it isnt. Speaking of acceptance can easily
be heard as changing your opinion or evaluation of some negative event.
We need to distinguish acceptance from approval, wanting, or liking.
One may accept thoughts about a cancer diagnosis without approving of
cancer and certainly without wanting or liking cancer. Acceptance, as
we mean it in ACT, is independent of judgment and desire. This includes
both positive and negative judgments. Acceptance means that when a
particular experience arises, we can acknowledge it, be present to it, and
take it in without attempts to alter it in any way. We may have judgments about the thought: I dont like it! However, having a negative
judgment about a thought is not equivalent to experiential avoidance.
Experiential avoidance would involve acting to reduce, eliminate, or
control the thought.

Acceptance Isnt Resignation


Another subtle distinction is between acceptance and resignation.
Resignation involves some aspects that are similar to acceptance. For
example, if you are resigned to something, you may no longer fight it.
However, resignation often involves a sort of giving up on life and on
possibilities. Acceptance in ACT is more like opening up than it is like
giving up.
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Mindfulness for Two

Why Is Experiential Avoidance Important?


Experiential avoidance can interfere with valued living. (And here
we begin to see examples of how the different core processes reflect and
affect each other.) Experiential avoidance is important when that which
is unacceptable lies between us and the things we value. For example, a
person with a history of childhood sexual abuse might occasionally experience thoughts, memories, and bodily sensations related to the sexual
abuse. These might be more likely to occur in situations involving physical intimacy or perhaps even in settings where physical intimacy was
imminent or even possible. Yet it may also be the case that this individual
values a relationship of which physical intimacy is a part. Avoiding these
behaviors to reduce or control the private events associated with sexual
abuse may do something to moderate discomfort in the short term, but it
may also stand in the way of a chosen valued direction.
If a person were completely unwilling to have those thoughts, he
could act to reduce or eliminate them. When we describe that which is
unacceptable, we describe the edges of the world we are free to inhabit.
To deem thoughts and emotions related to sexual abuse unacceptable
means that the person cannot go where those thoughts are likely to
emerge. It might mean that the person will avoid intimacy, struggle to
suppress those thoughts, or perhaps to even dissociate during intimate
relations. If the person values intimacy, nonacceptance of those thoughts,
emotions, and bodily states is a barrier to the pursuit of intimacy.
Under some circumstances, experiential avoidance can make bad
things worse. Theres a growing body of literature that suggests that
attempts to suppress negative thoughts and emotions can have detrimental effects (Purdon, 1999; Roemer & Borkovec, 1994; Wegner, Schneider,
Carter, & White, 1987). Theres also a body of evidence that suggests
that openness and acceptance fosters good long-term outcomes (Gifford,
Ritsher, McKellar, & Moos, 2006; Hayes, Bond, Masuda, & Lillis, 2006).
For example, James Pennebaker pioneered a series of writing studies
in which participants wrote about difficult situations. Most of the studies
involved participants writing about a difficult topic for approximately
twenty minutes on three separate days. In their writing instructions, they
were encouraged to write about their deepest feelings regarding the difficult topic.
Pennebaker and other researchers have found quite surprising results.
A group of workers laid off from their jobs who wrote about the pain of
being laid off were reemployed more rapidly than workers who didnt do
this writing (Spera, Buhrfeind, & Pennebaker, 1994). College freshmen
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The Hexaflex Model and Mindfulness from an ACT Perspective

who wrote about their difficulties in school showed fewer health care
visits and better grades (Pennebaker & Beall, 1986).

Is Experiential Avoidance Bad?


We should be cautious about overextrapolating from these data and
crusading to help everyone around us emote and express every difficult
experience. A good recent example can be found in the literature on
critical incident debriefing, which has been shown to actually cause harm
to some individuals receiving the treatment (Rose, Bisson, & Wessely,
2003). Likewise, not all individuals or populations in Pennebaker type
writing studies show benefits.
From an ACT perspective, experiential avoidance is neither good
nor bad in itself. Experiential avoidance is bad when, if, and just to
the extent that it interferes with valued living. Its relatively simple to
think of instances in which experiential avoidance is entirely benign.
Distracting yourself at the dentists office by looking at the ski poster on
the ceiling, taking a mild sedative before the appointment, or asking for
nitrous oxide has little negative impact on your dental work or probably
any other value, even if its done in an attempt to reduce anxiety.

Acceptance in Behavioral Terms


Difficult psychological experiences are likely to generate the sort of
strong antecedent aversive control I described in the last chapter. As
youll recall, such stimulus control generates relatively narrow and inflexible patterns of responding. Also, behavior repertoires like these are less
sensitive to aspects of context other than the difficult material and ways
to reduce contact with it. This is precisely why experiential avoidance is
often at odds with valued living. Many domains of valued living, such as
intimacy, are enhanced by moment-by-moment sensitivity. To speak in a
very ordinary way, it would be tough to be the most sensitive lover if you
were busy suppressing thoughts of abuse. In behavioral terms, acceptance
is an alternative response to difficult psychological experiences.

Reflections on the Clinician


Consider the value youre pursuing as a therapist while in the room,
working with a client. Ive suggested that youll see subtle shifts in the
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Mindfulness for Two

patterning of your clients behavior during a session. If your own behavior


is under strong antecedent aversive control, its much more likely that
youll miss these transitions. For example, if youre in the room busily
trying to look competent, its more likely that your interventions will be
less sensitive to subtle changes in your clients behavior. Paradoxically,
you will be less competent.
This is a good place for you examine some of your acceptance issues
as they affect you in sessions with your clients. Please reflect on these
questions:

Would you rather feel incompetent or be incompetent?


What if being willing to accept feelings of incompetence
were the admission price to greater competence?

Would you be willing to pay that pricefor the sake of your


clients and for your own sake?

Dont rush to answer these questions. Just hold them lightly for a
while and see what shows up for you. When youre ready, ease into the
exercise below. Consider first the things to you tend to avoid when youre
in session with your clients. Then think about what behavior repertoires
you engage in to keep these hard things away from you. Finally, consider
what the real consequences of this avoidance have been, both for you
and for your clients. I really encourage you to take your time with this. It
may be very hard for you, but if youre inventorying these things in the
service of something you valuenamely being an instrument of change
in the lives of your clientsI think youll be rewarded.

EXERCISE: Reflections on Acceptance


Mull over or write in your journal about the following questions:

What are the biggest things I avoid in session?


What behavior repertoires do I use to keep these hard things
away?

What have the consequences of these choices been?

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The Hexaflex Model and Mindfulness from an ACT Perspective

DEFUSION
Defusion means making contact with verbal products as what they are,
not as what they say they are. By extension, defusions opposite, fusion,
means taking these verbal products very literally, investing them with
authority and consequence. I know this definition sounds daunting and
technical, but we can look at it in a less technical way. Verbal product just
means that some event, either internal or external, has meaning as result
of verbal learning processes.
Sometimes verbal means actual words, like a thought you might
have (for example, I think Ill skip this section of the book). Things other
than words can also be verbal from this perspective. So, for example, if
you felt a palpitation in your chest, what you just experienced is a physical sensation. However, if a friend recently had a heart attack, the palpitation might be experienced as bad, frightening, or a precursor to a heart
attack, or as an occasion to go to the doctor, to increase your life insurance, to rethink eating that second donut, to start an exercise program,
to start taking your blood pressure medication again, and so forth. All
that from a little physical sensation! How did that sensation come to
mean all those things? Largely through verbal learning processes.
Words have an amazing capacity to make monsters present. We
confuse words with the things that the words point to. We do this sometimes when the thing pointed to doesnt even exist. There was a time
when many people wouldnt sail far out to sea for fear of falling from
the edge of the flat earth. Zen teachers sometimes say that the finger
pointing at the moon isnt the moon. We might need to go further still
the finger pointing at the moon isnt the moon, and, further, even the
moon isnt the moon.

Why Should We Care About Fusion?


Just so we dont drown in a sea of abstraction, lets look at the ways
we see fusion in clinical examples. If someone with agoraphobia responds
to the thought that shes having a heart attack as if shes actually having
one, shell go to the hospital again and again. If a student sitting in a
classroom has the thought that everyone in class understands except
him and acts as if that thought is so, he remains quiet and benefits less
from the class. This seems to raise issues related to the veracity of the
thoughts. Imagine, however, in the classroom example, if it were actually
the case that everyone else understood. Remaining silent would still be
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Mindfulness for Two

ineffective if the value being pursued were being educated. In ACT, were
concerned much more with workability then veracity. What, though, is
to be done with such troubling thoughts?

Contrasting ACT and Traditional Accounts of the


Role of Cognition
Traditionally, cognitive therapists have focused on the veracity of
thoughts and encouraged a dialogue and series of behavioral experiments that are aimed at examining and ultimately refuting inaccurate
thoughts. The core change mechanism is the supplanting of negative
and inaccurate thoughts with more positive and accurate ones, with the
assumption that altering the content of thoughts will alter behavior and
emotion. The underlying assumption in cognitive therapy seems intuitively obvious. Its consistent with cultural admonitions to take a positive
attitude and to be certain of the facts before taking action. Yet this model
has come under increasing scrutiny in recent years.

The Example of Self-Esteem


Consider, for example, the movement to improve self-esteem.
Programs to raise self-esteem have proliferated all over the United States
for the past thirty years. However, just because its true that having positive thoughts about oneself is correlated with positive outcomes doesnt
mean that interventions aimed at generating positive self-concept will
necessarily produce those outcomes. The following was a conclusion
drawn in a recent meta-analysis of the self-esteem literature:
We have not found evidence that boosting self-esteem (by therapeutic interventions or school programs) causes benefits. Our
findings dont support continued widespread efforts to boost
self-esteem in the hope that it will by itself foster improved
outcomes. In view of the heterogeneity of high self-esteem,
indiscriminate praise might just as easily promote narcissism,
with its less desirable consequences. Instead, we recommend
using praise to boost self-esteem as a reward for socially desirable behavior and self-improvement. (Baumeister, Campbell,
Krueger, & Vohs, 2003)
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The Hexaflex Model and Mindfulness from an ACT Perspective

The Example of Cognitive Therapy


Cognitive therapy, more so than any previous therapy model, focuses
on cognitive change as the central mediator of clinical improvement.
Ill offer a critique of cognitive therapy, but I want you to understand
that I do so holding close the words attributed to Bernard of Chartres
and repeated through the centuries by the likes of George Herbert, Isaac
Newton, and Samuel Taylor Coleridge: we can see further than giants
when we stand on their shoulders. In that light, please recognize that I
know that this critique wouldnt even be possible except for the remarkable and forward-thinking work of individuals like Aaron Beck and
Albert Ellis, among others who rightly asked about the role of human
thinking in psychological problems. Contemporary variants of cognitive
behavior therapy (CBT) share this view: Only in instances where cognitive change can be demonstrated, and where cognitive mediation is an
important component of the treatment plan, can the term cognitivebehavioral be applied (Dobson & Block, 1988, 7).
Although cognitive therapy focuses on cognition as the key mediator of change, it has always included direct behavioral interventions in
the form of behavioral experiments. Behavioral activation, a behavioral
component of traditional CBT in which clients develop a hierarchy of
reinforcing activities and then set goals within that hierarchy as a means
of reconnection to naturally occurring sources of reinforcement, involves
activities done outside session that have the potential to disconfirm irrational negative beliefs. Other interventions aim at relatively situationspecific negative automatic thoughts (NAT). A large number of variants
of automatic thoughts have been identified, including selective abstraction, maximizing, minimizing, and overgeneralizationand the list
goes on. Still other cognitive therapy interventions target core cognitive
schemas, fundamental cognitive structures relevant to a persons construction of self, others, the future, and the external world.
In deconstructing cognitive therapy into its constituent parts, the
late Neil Jacobson attempted to test whether direct intervention on
cognition, both local (NAT) and global (core schemas), could account
for improvement in cognitive therapy. He designed a study that used
three conditions in the treatment of depression. The first involved the
full cognitive therapy package, including work on behavioral activation,
intervention on negative automatic thoughts, and finally work on core
schema (well refer to this one as CT). A second treatment condition
involved only the behavioral activation and negative automatic thoughts
components (NAT). A third and final condition involved behavioral
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activation (BA) alone with no cognitive interventions allowed (Jacobson


et al., 1996).
At posttreatment as well as at a two-year follow-up, the three treatment conditions were virtually identical on every criterion measure,
including recovery and relapse rates, number of well weeks, and survival
time to relapse (Gortner, Gollan, Dobson, & Jacobson, 1998, 380381).
The authors concluded that the full CT package was no more effective
at preventing depressive relapse or recurrence than either of its component parts (Gortner et al., 1998, 381).
The efficacy of cognitive therapy was not called into question in
this study. In fact, the outcomes in Jacobsons trial were comparable to
outcomes in previous trials that demonstrated the efficacy of cognitive
therapy. It was the mechanisms by which cognitive therapy works that
were called into question as Jacobson asked whether direct cognitive
interventions added anything to the treatment. A more recent study
examined the differential effects for CT versus BA for low versus high
levels of depression. For individuals with low levels of depression, the
study showed the same equivalence of outcomes as Jacobson and colleagues. However, for high levels of depression, BA alone actually outperformed the CT condition (Dimidjian et al., 2006).
Questions about underlying mechanisms of cognitive therapy are not
new and are not restricted to critics of the theory. These questions also
come to us directly from the originators of the model. In 1986, Steven
Hollon and Arron Beck stated that there is not, as yet, compelling evidence that cognitive therapy works, when it works, by virtue of changing
beliefs and/or information processing, although that remains a very viable
possibility (446448). And in 1994, they said, It is not clear whether
these interventions work, when they work, by virtue of changing beliefs
or thinking, as specified by theory (Hollon and Beck, 1994, 458).

An ACT Perspective on the Role of Cognition


ACT takes a very different view of cognition than is typical in the
culture in general and in psychology specifically. The concern in ACT
isnt with the content of cognition. Rather, its with the ways in which
cognition stands in for the world, accurately or inaccurately, and the
ways it organizes behavior to diminish or make impossible valued living.
In ACT, we call such instances fusion.
Fusion is the process whereby certain verbal functions of events
exert strong stimulus control over responding to the exclusion of other
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The Hexaflex Model and Mindfulness from an ACT Perspective

directly and indirectly available psychological functions. The reason


this is limited to verbally established events is to distinguish the sort
of narrowing of responding that might occur if someone were to say to
you, You are an incompetent therapist, as opposed to the narrowing
of responding we might see resulting from, say, a loud explosion. The
former is made possible as result of verbal processes, whereas the loud
explosion would likely narrow the repertoire of any creature capable of
hearingwhether that creature were verbal or not.
Mere awareness of that something, though frightening, is benign
doesnt seem sufficient. Its entirely common for people with agoraphobia to know that their fears are overblown, for those with alcoholism to
know they need to stop drinking, and for individuals struggling with
depression to know they must get up and meet the day. In ACT, we foster
interactions with thoughts that have the effect of broadening repertoires
in their presence. In some ways, this work is analogous to exposure-based
treatment. Lets consider a specific phobiasay, fear of snakes. People
with specific phobias make wonderful case studies in this area because,
by definition, they have some awareness that their fears arent accurate.
If a person has a snake phobia, we wouldnt even consider trying
to convince her that a nonvenomous snake is safe. Instead, what we do
is have the person interact with snakes in a variety of ways, excluding
avoidance. What results is that the persons behavior becomes increasingly flexible in the presence of snakes. This core treatment strategy
is among the most demonstratably effective in behavior therapy. It is
ironic that when our clients repertoires are narrow and inflexible in the
presence of snakes, we do exposure. When their repertoire is narrow
and inflexible in the presence of heights, we do exposure. When their
repertoire is narrow and inflexible in the presence of crowds of people,
we do exposure. Yet, for some reason, a very different approach is traditional in cognitive therapy when a clients repertoire becomes narrow
and inflexible in the presence of a thought: Im a loser, Im unlovable, Im
a lousy therapist. We try to talk themand even ourselvesout of the
thought.

Is Fusion Bad?
I know, Im starting to bore you. However, if you already know the
answer to the question Is fusion bad? Im beginning to make my point.
No. Fusion is not bad or good. Fusion simply is. In fact, theres extraordinary adaptive advantage to fusion. When one early hominid said to the
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Mindfulness for Two

other, Dont go to the water hole, theres a lion there, if the other hominid
responded to the word lion as if he was responding to an actual lion, he
survived. Only one of these individuals actually saw the lion, but his words
made the lion present for his friend. In the end, they both lived.
Its relatively simple to generate examples of fusion that are benign
and sometimes even very helpful. For example, being deeply engaged
with the words of a novel to the point where you lose awareness of things
going on around you is good entertainment. If youre about to step into a
crosswalk and someone shouts, Watch out for that car! you might leap
from the street in response to the words in the same way that you might
respond to the actual car. Here fusion isnt only benign, its also adaptive.
There are many times, however, when fusion leads to behavior thats
directly contradictory to valued living. When the person with an alcohol
addiction drinks in response to the thought I cant stand these cravings,
when the someone with agoraphobia stays home in response to I cant
stand another panic attack, or when a depressed individual stays in bed in
response to I cant face this day, opportunities to live a vital and engaged
life are lost.

Fusion in Behavioral Terms


Theres a long story and a short story to be told here. Ill hint at the
long (and technical) story and actually tell the short one. The short story
is that fusion will very often involve aversives made present by verbal
processes, and theyll precipitate a narrow, inflexible, and relatively
insensitive repertoire. In fact, many of the things we discussed as avoided
events in the previous section on experiential avoidance are aversive as
result of fusion.
Consider the thought Im a loser. No one will ever truly love me, and Ill
die alone. Such a stream of thought or even the hint of that thought might
precipitate experiential avoidance on the part of a client (for example,
drinking, avoiding dating, working sixteen-hour days). Looking through
the fusion facet, we see that the client isnt making contact with the fact
of dying alone. How could he? Hes making contact with the thought of
dying alone.
Practicing acceptance of the thought might be one alternative way to
interact with the thought, but ACT offers many. We might ask the client
to say the thought rapidly over and over again. We might ask the client
to close her eyes and imagine that the thought is like an object in front
of her in space and then ask that she imagine giving it a color, a size, a
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The Hexaflex Model and Mindfulness from an ACT Perspective

shape, a temperature, and a texture. All of these exercises are aimed at


reducing the dominance of the aversive functions of the thought while
not necessarily changing the content of the thought.
Its part of the human condition that we create stories about ourselves
and about the world around us. Our stories are often filled with limitations, and we proceed to live our lives inside those limitations. If clients
have many things they can do in the presence of a thought or series of
thoughts rather than only one thing, they are freer. And ACT is about
freeing people from narrow patterns of activity that inhibit valued living.

Reflections on the Clinician


As a therapist, if you want to understand this process in your own
work, consider which thoughts show up for you as uninvited guests.

I must do ACT well!


I dont think I can help this client.
I cant stand this client.
This client is sooooooo boring!
Watch the way these thoughts organize your behavior. And while
youre doing what you do with those thoughts, whats the client doing?
How much awareness do you have of the patterning of his responding?
What if you could learn to have your own thoughts as thoughts, and do
what you value in that room? Would you be just a little freer in that room?
Below, youll find an exercise to help you reflect on these questions.

EXERCISE: Reflections on Defusion


Mull over or journal about the following questions:

What thoughts often occur to you in the therapy room?


What is your client typically doing when these thoughts
come up?

What would it look like if you could have these thoughts


and still do what you value in that room?

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SELF-AS-CONTEXT
Questions of self in ACT are often focused on what might be called
fusion with self-as-content. Self-as-content involves strong identification of oneself with prominent contents of consciousness, such as mood,
thought, role, or bodily state. Self-as-context, by contrast, refers to the self
that has experienced every thought, emotion, role, and bodily state you
have experienced. This self is sometimes called the observer self or the
transcendent self.
Of course, there are many ways that we can understand self, including scientific views and spiritual views, among others. In order to understand self from an ACT perspective, one must understand a behavioral
view of self. This view doesnt preclude other views; its simply a way, not
the way, to understand self. From a behavioral perspective, self is not a
fixed entity (Hayes, 1984; Skinner, 1972). Self, or perhaps more properly
selfing, is a particular stream of behavior. As such it is shaped in an
ongoing and dynamic way by the context in which it exists.
Early in life, children make mistakes in distinguishing their own perspective and that of others. Over time, theyre asked many, many questions about their own perspective and that of others. What did you have
for breakfast? What did your brother have? Your sister wants ice cream.
What do you want? Where were you this morning? Whats your favorite
color? Through this series of questions, we learn to answer from a relatively consistent perspective. Like any behavioral pattern, however, its
not entirely fixed. Different contexts can change what we see, feel, and
think, and, importantly, even our sense of identity.
Self is conceived as an ongoing stream of behavior that one is born
in and as being dynamically shaped by that crucible of questions the
answers to which begin with I. A narrow focus on difficult content has
the potential to narrow the breadth of the experience of self. Consider,
for example, an individual with psychosis presenting to a mental health
professional. Almost certainly the three most consistent questions that
the counselor or therapist will ask him will be have you been taking your
medications, have you been having any side effects, and have you been
having any symptoms (for example, hearing voices, thoughts of persecution, and so forth)? If Im the individual with psychosis and my experience of myself is being shaped in a crucible of questions, what self is being
shaped here? Its worth asking ourselves if our focus on client difficulties
contributes to a narrowing of the experience of self. Are we helping to

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The Hexaflex Model and Mindfulness from an ACT Perspective

perpetuate a subset of fused thoughts about self, where symptoms and


roles of a mentally ill person stand in for the person as a whole?
Its problematic that the more distressed the client, the more likely
well find ourselves drawn to questions about distress. Problems are very
salient and get our attention. (Remember the bear and the blueberries.)
When our clients most need to cultivate flexibility, we ourselves are,
ironically, most likely to become focused on distressing contentand we
ourselves lose flexibility (in the form of therapist fusion and avoidance).
In the chapters that follow, Ill use experiential training methods to help
you learn to cultivate a certain posture of equanimity with respect to
distressing client content. In doing so, well embody the ACT principles
we desire to cultivate in our clients. To the extent that we open up our
clients distress (and our own!) and connect with it, we will be empowered to foster flexibility in our clients, helping them let go of distress and
open up to other aspects of their experience.
In order to discriminate a sense of self thats distinct from the contents of consciousness, multiple exemplars are required. To the extent
that our clients are engaged in a broad set of questions, in a slow and
deliberate fashion, theyre more likely to notice the I that notices, the
observer self. Focus on difficulties alone carries the risk of fostering fusion
of self with difficulties (that is, I = depressed; I = anxious). In the service
of noticing the transcendent sense of self, we bring our attention to bear
in therapy on both sweet and sad moments. We move with flexibility
and deliberate pacing among questions about values, vulnerabilities, and
struggles.

What Causes Us to Lose Contact with Self-as-Context?


The most prominent causes of loss of contact with self-as-context
are fusion and avoidance. As I mentioned above, fusion with self-ascontentexcessive identification with certain emotions, memories, or
rolesis generally the immediate cause of this loss of contact. Other
forms of fusion will also generate a lack of awareness of self-as-context.
For example, perceived threat or any event related to threat would be
likely to precipitate such a loss of contact. This makes good sense, since
fusion, especially with respect to aversives, has such a powerful connection to contingencies of survival. We must imagine that awareness of
predators was much more valuable on the savanna than awareness of
ones sense of self as a unique and omnipresent perspective.
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Is Loss of Contact with Self-as-Context Bad?


Here we go again. In this case, though, I think youll find that a
loss of contact with self-as-context is generally benign. However, in the
midst of a sea of aversives, contact with a sense of self that transcends
all of those experiences, present and past, provides a life raft in an often
stormy sea. Once again, its the degree to which this lack of contact
interferes with valued living that makes it either adaptive or maladaptive
to the individual experiencing it.

Self-as-Context (or Content) in Behavioral Terms


My discussion of fusion in the section above also applies to fusion
with self-as-content where the content is aversive: Im the kind of person
who cant keep a job, Im not the marrying type, People like me cant go to
graduate school, and so forth. Such content will have the same narrowing impact on behavior. The remedies within ACT will be the same:
acceptance and defusion. In addition, selfing is itself a repertoire thats
in dynamic interaction with context. We can organize our interactions
with our clients so as to cultivate broad and flexible patterns of selfing.
We do so by asking many questionssweet, sad, and mundanethat
will grow that repertoire.

Reflections on the Clinician


For the therapist, the same medicine applies. What are the stories
you tell yourself about who you are and who you must be as you sit in
that room? In what ways do those narrow your activity and sensitivity?
Can you notice the you who notices all those repertoiresfor good and
ill? Can you act with kindness and flexibility when you encounter those
limiting versions of you that come and go?

EXERCISE: Reflections on Self-as-Context


Mull over or journal about the following questions:

What stories do you tell yourself about who you are as you
sit in the therapy room?

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The Hexaflex Model and Mindfulness from an ACT Perspective

How do you think these stories might affect your clients?


What behaviors do you engage in to reinforce these stories
or suppress them?

CONTACT WITH THE PRESENT MOMENT


Contact with the present moment involves an individuals capacity to bring
attention to bear in a focused, deliberate, yet flexible fashion. Contact
with the present moment, thus defined, is distinguishable from relatively
rigid and fixed attention as might be seen, for example, in video-game
play. While observing someone fixated on the screen of a first-person
shooter, you might find considerable focus in the present moment but an
extreme absence of flexibility. Contact with the present moment should
also be distinguished from distractibility. Distractibility shows flexibility
in attention to different stimulating events, both external (for example,
sounds and sights) and internal (such as thoughts, emotions, and bodily
sensations), but lacks the deliberate, focused quality we seek.
The most striking case of the failure of present-moment contact is
probably dissociation, where the environment around individuals has
virtually no impact on them. Much more common presentations include
worry and rumination. In worry, individuals lose contact with the present
moment as they focus their attention on a conceptualized future. In rumination, the present is lost to a fixation on a conceptualized past. Note
also that both of these also can be examined as instances of fusionone
with a verbally presented past and the other with a verbally presented
future. Deep indulgence of either worry or rumination leaves individuals somewhat insensitive to moment-by-moment interactions with the
world around them. Clinically, we might experience such an individual
as preoccupied or detachednot quite there. Research suggests that
worry and rumination are engines of sustained psychological difficulties
(Nolen-Hoeksema 2000; McLaughlin, Borkovec, & Sibrava, 2007).
Tom Borkovecs pioneering work in generalized anxiety disorder
(GAD) has shown that bringing individuals into the present moment by
using relaxation exercises caused greater anxiety in subsequent exposure
sessions and, importantly, greater benefit from those exposure sessions
(Borkovec & Costello, 1993). In early accounts of the role of relaxation,
the so-called relaxation response was thought to counter the anxiety
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response. Borkovecs work suggests that it in fact facilitates anxious


responding.

What Takes Us Out of the Present Moment?


Often what takes us out of the present moment is some painful
event. Theres a reciprocal relationship between contact with the present
moment on the one hand and experiential avoidance and fusion on the
other. Experiential avoidance and fusion have a very difficult time surviving in the present moment. For example, we can take even the most
fused thought and get very present to it, to the bodily states that arise
with the thought, to the inclinations to act that are associated with the
thought, to the emotions that come with the thought. If we slow the
interaction down and coach the client to express, moment by moment,
each of these aspects of experience, if we ask the client to linger with
each and breathe thoughts and emotions slowly in and out like air, fusion
and avoidance tend to evaporate in the interaction. What emerges with
painful events is a richer appreciation of the experience of life surrounding the event and a better capacity to respond to the painful event with
sensitivity. The pain does not typically go away; it just ceases to dominate the clients capacity to act.

Is Not Being Present Bad?


Yes, it is.
Of course Im not being serious. As with all the other core-process
breakdowns, you shouldnt understand not being present as intrinsically
bad or good. From an ACT perspective, things are only workable or
unworkable in the context of a given value. Its simple to point to examples when precisely the same act in different contexts might be quite
workable or quite unworkable. Daydreaming involves a loss of contact
with the events around us. On a spring day, lying out on a blanket in the
warm sun, daydreaming might be a fine thing to do. However, the same
act of daydreaming while driving could be disastrous.

Contact with the Present Moment in Behavioral Terms


From a behavioral perspective, the value of being in contact with
the present moment is easy to see. If you are to learn and be shaped by
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interactions with the environment, you need to be there to interact with


it. This doesnt merely mean that you must be there physically. You need
to be psychologically present. If you have a fear of dogs or spiders, for
example, you must interact with dogs or spiders in a variety of ways in
order for their fearsomeness to recede for you.
In nonclinical examples, sitting in the classroom daydreaming and
looking at the clouds will not help you to learn algebra. To learn algebra,
you must interact with formulae, numbers, and symbols of various sorts.
Similarly, to interact effectively with the complex world around us
career, family, interpersonal relations, personal carewe must be teachable. The world cant and wont teach us what works unless we learn to
pay attention. The capacity to bring attention to bear in a deliberate,
focused, yet flexible way is thought to enhance learning of all sorts. The
good news is that flexible, focused attending is behavior. It can be learned
and enhanced through practice. The shaping of this capacity and the fostering of increased contact with the present moment is central to ACT.

Reflections on the Clinician


Present-moment contact is every bit as important for you as a therapist as it is for your clients. You need to ask of yourself the same questions you ask of your clients. To the extent that you become excessively
attached to a conceptualized future for your clients (What if I cant
help them?) or a conceptualized past (Ive done them no good at all),
youll be less available to interact with the small shifts in their behavior.
In addition, to the extent that youre worried and anxious and working
hard to make these painful thoughts go away, your clients may begin to
help you out by expressing less distress.
This responsiveness on the part of your clients to your distress is
not, in and of itself, problematic. If youre invested in your clients pursuit
of their values, youll likely feel sadness when they suffer a loss. Unless
theyre in extraordinary and acute pain, its very likely that theyll offer
such help. The help they offer is likely organized by two streams of stimulus control. First, your pain is painful to them, and they may act to
avoid it. However, they may also be acting out of kindness for you. If
you yourself are able to bring flexible focused attention to bear in the
present moment, youll be better able to interact with your clients in a
way that honors their compassion without co-conspiring in their avoidance. Seeing both streams of stimulus control, you might offer, I feel
pain when you feel pain. I know thats hard for you to see, but please
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know that Im here by choice. Im honored to walk in pain with you. To


see both values and avoidance simultaneously and to respond effectively
will require you, in the room, to attend closely. Once again, heres an
exercise with some questions for you to consider.

EXERCISE: Reflections on Contact


with the Present Moment
Mull over or journal on the following questions:

At what times do I tend to lose contact with the present in


therapy sessions?

How might these moments affect my clients?


What might it look like if I could remain in the room during
these moments? How might my presence be of service to my
clients?

VALUES
Values are understood in many ways in different psychological, philosophical, and spiritual traditions. Values are, in an important sense,
central to ACT. They direct and dignify the difficult work we do. As
we move in the direction of our values, obstacles emerge. When these
are obstacles in the world, we have our life task before us. When the
obstacles are thoughts, emotions, and the like, we have a different sort
of life task. From an ACT perspective, the task is openness, acceptance,
and defusion in the service of movement in a valued direction.

Values in Behavioral Terms


In ACT, values are freely chosen, verbally constructed consequences
ofongoing, dynamic, evolving patterns of activity,which establish predominant reinforcers for that activity thatare intrinsic in engagement
in the valued behavioral pattern itself. (Whew! Well look at the various
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The Hexaflex Model and Mindfulness from an ACT Perspective

aspects of this definition soon. Just hang tight.) Please, please note here
that Im not asserting that this definition exhausts what is meant by
values in any global sense. Rather this is a way of understanding values
as we use them in ACT.

VALUES ARE FREELY CHOSEN


In ACT, values are not feelings. Although one may have very strong
emotional responses in different valued domains, the two arent equivalent.
Key to the distinction is that values are chosen patterns of activities that
can be actively constructed by an individual. In some ways, the construction of values can be thought of like the construction of a house. Emotions
are more like the weather where the house is built. Emotions often come
and go. They may have patterns, but they arent chosen. Even thoughts
often have this quality. If we attempt to actively have and not have certain
thoughts, such purposeful manipulation has the potential to backfire.
To use a specific example that illustrates the distinction between
thought and emotion as values versus chosen patterns of activity, consider the area of racial prejudice. If you were raised in the United States
(or many other places), youve likely grown up in a culture in which its
more accurate to ask, In what ways am I racist? than to ask, Am I
racist? Our culture (if you are Americanperhaps even if youre not)
carries the baggage of racial oppression, and it takes a very long time for
such things to change. Even when we personally value the practice of
racial equality and abhor the idea of racial supremacy, we still carry some
of the seeds of these prejudices. I think hard, as a teacher, about ways in
which I can foster open dialogue about prejudice. Im active in my consideration of the ways our department makes hiring decisions and the
ways our doctoral program selects students. I construct learning activities that help reveal the ways that prejudices alter perception even outside
our awareness. Yet I know that Im not immune to these influences. Just
because Im susceptible to racist thoughts and feelings, though, doesnt
mean I cant continue to chose the value of racial equality even when my
thoughts and feelings dont always cooperate.
In fact, many, many of our most deeply held values are like this.
Sometimes we feel very faithful to our roles as parents, spouses, or professionals. Sometimes we dont. Sometimes we have very values-consistent
thoughts about these activities. Sometimes we dont. However, we may
choose to pursue a valued direction regardless of these thoughts and
feelings. Part of the value very likely includes a certain steadfastness in
the face of difficulties, both without and within.
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Mindfulness for Two

VALUES ARE VERBALLY CONSTRUCTED


ACT is based on a post-Skinnerian behavioral theory that includes
relational frame theory (RFT), a relatively new account of human language and cognition. According to RFT, relational or verbal conditioning
processes are capable of making present psychological functions without
the necessity of direct conditioning processes. Take as a case example
Frankls experience in the death camps of Nazi Germany. One would
be hard-pressed to generate a direct conditioning account of his act of
staying in the camp. There were few, if any, reinforcers in the camp for
Frankls decision to remain. Rather, his reinforcer was intrinsic in the
match between his decision and his own verbal construction of what it
meant to be both a doctor and a human being.

VALUES ESTABLISH REINFORCERS


ACT is a contextual behavioral treatment, and as such the language of values is a special way to speak about reinforcement among
verbally competent human subjects. As I expand and articulate a pattern
of valued activity, I simultaneously establish reinforcers. For example, if
part of being a father means spending high-quality time with my children, acts such as taking long family vacations, going to swim meets,
and wandering the shopping mall become intrinsically reinforcing to the
extent that they are part of the pattern.
Reinforcers for nonhumans, with a few exceptions, consist of a relatively small set of evolutionary imperatives: primary reinforcers such as
food, shelter, water, sex, and social contact for some species, as well as
the events correlated with those imperatives, which we know as secondary reinforcers. Humans, by contrast, often value things that defy direct
conditioning accounts: for example, reaching nirvana.

VALUES ARE ONGOING PATTERNS OF ACTIVITY


In ACT, values are distinguished from goals. Goals are achievable
ends. Values are patterns that can be abstracted from ongoing streams
of complex human behavior. For example, getting a degree is a discrete,
achievable end. Education might be a relevant value that could continue
for a lifetime. ACT uses goals, as do many other behavioral interventions. However, in ACT goals are explicitly directed by client values.
It is important to say that values are not so much discovered as constructed in the ACT model. Talk about true values or real values
misses the mark. Using the house metaphor, we could imagine the house
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The Hexaflex Model and Mindfulness from an ACT Perspective

we would want to live in. We could plan it and begin its construction. We
might make changes along the way. One day we might find ourselves living
in a house that was quite comfortable, one that fit our lives. It would be
odd to ask, Is this my true house? No. Its the house you built. Do you like
it? If not, what would you change? In the case of values, we ask, What is
the pattern I have made? How will I build it from here? There is an active
quality to such a line of questioning and one that is much less likely to lead
to incessant second-guessing about the truth of ones values.

VALUES ARE DYNAMIC AND EVOLVING


Values in ACT are evolving patterns of activity. Consider parenting,
for example: the pattern of activity that defined being a good dad to my
daughter at two years of age is different than being a good dad when she
is thirty-two.
The primary reinforcer is intrinsic to the act itself. Frankls story
is an apt example of such a pattern of activity. The predominant reinforcer described by Frankl is to be found in the consistency of his actions
with his ongoing construction of what it meant to be a doctor and, more
broadly, a person.
Because were talking about reinforcement, the behavior of interest is
what we call operant behaviorthat is, behavior thats sensitive to both
antecedents and consequences. We should be aware, though, that theres
an intimacy between values and vulnerabilities. As described earlier, values
and vulnerabilities are always poured from the same vessel. When were
working on values with clients, theres also a high likelihood that related
vulnerabilities will surface. This is especially likely where clients have had
losses or personal failures in their history. For example, if someone has a
history of behaving poorly as a parent, talking about that value is as likely
to generate aversive control with all its repertoire-narrowing effects as it
is to generate positive life change. To the extent that the person deeply
values parenting, the potential for fusion and avoidance is increased. If
the person didnt value parenting, the domain would be a matter of indifference. A conversation about parenting would be unlikely to generate
motivation, but it also wouldnt produce fusion and avoidance.

Reflections on the Clinician


In order to understand the double-edged qualities of the facet of
values, its worthwhile to examine the ways these matters play out in
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Mindfulness for Two

your clinical work. What is it that you value in the work that you do? Or,
said another way, who would you like to be in the lives of your clients? At
workshops, I sometimes ask people to imagine that theyre at the therapist buffet. I then describe the dishes available to them: here we have
lousy therapist, then okay therapist, which is followed by pretty good
therapist, and in this last dish, we have amazing therapist. Which would
you like? Remember, this is a buffet. You can have any one you want.
Sometimes I ask people to say out loud what they want. Imagine what
this would be like for youto say out loud in a room full of therapists
what kind of therapist you want to be. Imagine I ask you to look around
the room, into the eyes of your peers, and then to say to them, I want
to be an amazing therapist. Imagine saying it loud enough to be heard
clearly and unambiguously. Imagine owning whatever comes up. What
do you feel? Can you feel a bit of constriction? A bit of reluctance? A bit
of hesitation? And let me ask the same thing of you right now: What if it
were possible for you to be an instrument of extraordinary change? What
if you could be an instrument of liberation in the lives of your clients? See
if you can feel the push and pull that arises when you consider claiming
that possibility.
As is often the case, poets express these kinds of tensions in ways
that behaviorists and psychologists might not:
Do I dare
Disturb the universe?
In a minute there is time
For decisions and revisions which a minute will reverse.
For I have known them all already, known them all
Have known the evenings, mornings, afternoons,
I have measured out my life with coffee spoons;
I know the voices dying with a dying fall
Beneath the music from a farther room.
So how should I presume?
T. S. Eliot, The Love Song of J. Alfred Prufrock (1991, 45)
Why do Eliots words ring so true over so many years and in so many
lives? And you, do you know something about measuring life out with
coffee spoons? Do you dare? Do you dare? If you can let yourself know
that hesitation, that small tremor, and meet it with equanimity, and
breathe it in and out like air, and welcome it with acceptance and kindness, you might know something of the push and pull your clients feel
around their values.
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The Hexaflex Model and Mindfulness from an ACT Perspective

This next exercise is a monster. Dont feel like you have to come up
with the right answers. Remember that values are ongoing patterns
of activity. I hope, though, that youll take the time to sit with these
questions.

EXERCISE: Reflections on Values


Mull over or journal on the following questions:

What matters to me as a therapist?


What comes up for me as I write down those words, as I
claim this possibility?

What might it mean both to me and to my clients if I could


act to further this value?

COMMITTED ACTION
The last of our facets is committed action. Commitment in common
usage is often almost synonymous with a promise made with reference
to the future. While making such a promise might be part of a commitment, such a promise in no way exhausts what is meant by commitment
in ACT.
If we were always moving in a direction that was consistent with our
values, committed action would be synonymous with values. However,
committed action emphasizes the ongoing choosing and rechoosing of a
direction. Committed action, in flight, can be seen metaphorically in a
breathing meditation. In such practice, we choose our breath as a place
to bring attention to bear. Of course, what we find is that our attention
wanders. We begin to think of activities that we need to do later, or
perhaps different pains and discomforts capture our attention. When
we notice this, we may linger a moment. We meet our inattention with
equanimity, like meeting an old friend on the road. Hello, we say. We
let go of our inattention and gently return to our breath. I believe that
the heart of commitment lives in that gentle return.

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Consider a value like parenting. We choose parenting as a value and


evolve a pattern of activity consistent with our value. Some days, some
moments, we will be well oriented within that pattern. Other days, other
moments, well find ourselves at odds with our value. In that moment,
the moment in which we notice that were out of alignment with our
value, can we pause, notice our dislocation, and gently return? Its difficult to imagine a value of any magnitude that will not involve a lifetime
of gentle returns.
Theoretically, committed action isnt terribly distinct from values.
If you consider some valued domainsuch as parenting, career, being
a brother or sistermaking and keeping commitments is likely part of
the pattern. In this sense, commitment can be viewed as part of valuing.
From a practical perspective, though, there will be times when theres
great advantage to keeping commitment separated from values, if only
temporarily and strategically.
For example, when working with clients who have values that they
have long neglected or have violated in important ways, fusion and
avoidance are likely to be quite high. Consider the client with a substance abuse problem who has a history in which shes neglected or even
endangered her children. The client may have a story about how bad she
is as a person and may be very attached to that story. She may also avoid
any activity that brings her into psychological contact with parenting
because such contact is terribly painful.
For such a client, sometimes a line of inquiry that takes commitment explicitly off the table can be very fruitful. As a therapist, Ive
often been successful asking a client to help me to see in a very visceral way what he values in some domain without any commitment to
do anything. Sometimes doing present-moment-focused acceptance and
defusion work around a value can lessen fusion and avoidance enough
to make some small commitments possible. Well explore different ways
to structure interventions in a later chapter. For now, just consider this
subtle distinction between committed action and values.

Committed Action from a Behavioral Perspective


As mentioned above, committed action is in some ways not theoretically distinct from values. Part of the valued pattern is a persistent return
to the pattern when one strays. If done in the context of acceptance and
defusion, return to the pattern will itself be intrinsically reinforcing.
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The Hexaflex Model and Mindfulness from an ACT Perspective

Reflections on the Clinician


If being an instrument of change for your clients is a value you have,
you need look no further than that value and your interactions in the
therapy room to see opportunities for commitment in action. How many
times during a session have you found your own attention drifting to
matters other than the client? How many times have you found yourself
in therapy treating your client as if she were a problem to be solved? Can
you notice, in those moments, your values speaking to you? If you accept
their invitation and make that gentle return to your client and to your
value, youll know something of commitment. I invite you to linger a
moment in your next session over that moment on the cusp of return.
See if you can notice the intrinsic vitality of that return. Or, conversely,
if that is obscured, notice fusion that stands reprimanding you for having
to return again. And gently breathe that reprimand in and out like air,
make your return, and notice the shift in your own presence.

EXERCISE: Reflections on Committed Action


Mull over or journal on the following questions:

What

kinds of actions are you committed to in therapy


sessions?

When

do you notice yourself turning away from these


commitments?

Can you gently return to them? What does that look like
for you?

MINDFULNESS AND ITS RELATION TO


THE HEXAFLEX
Ill take Jon Kabat-Zinns definition of mindfulness as a starting point.
Jon suggests that mindfulness involves paying attention in a particular
way: on purpose, in the present moment, nonjudgmentally (1994, 4).
From an ACT perspective, I believe that mindfulness can be usefully
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Mindfulness for Two

understood as the convergence of the four processes on the left side of


the hexaflex: contact with the present moment, acceptance, defusion,
and self-as-context.
The most obvious ACT connection to mindfulness is to be found
in the here-and-now quality of mindfulness itself. We bring attention to
bear in a flexible and focused way to some selected object of attention in
the present moment. The focus component suggests the intentionality of
the individual who is being mindfulas Jon says, on purpose. Being
mindful of our breath, for example, is chosen. Each time our attention
drifts or is captured by something before or later, we return to our breath
in that very moment.
The nonjudgmental posture of mindfulness is captured by the acceptance dimension of ACT. In being mindful, many things arise. All are
met with openness. We bear witness with acceptance: to thoughts, emotions, memories, urges, and, paradoxically, even to the judgments that
will surely arise.

The ACT Hexaflex Model Showing the


Mindfulness Convergence

In coaching an accepting and open awareness of thoughts as


thoughts, of emotional reactions as emotional reactions, of sensations as
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The Hexaflex Model and Mindfulness from an ACT Perspective

sensations, we notice these things as ongoing processes rather than being


caught by the contents of consciousness. This is an example of defusion.
Thoughts, emotions, and the like continue to arise; however, they stop
organizing behavior in any strong sense.
When a client returns again and again to the present moment, witnessing with equanimity each thing that arises in awareness, he also
makes contact with a sense of himself thats distinct from the contents
of consciousness: the observing self or self-as-context. He may contact
self-as-context not just conceptually but also experientially.

Mindfulness and Defusion or Exposure


In a certain sense, mindfulness is, in and of itself, a defusion strategy. However, it can also be used in conjunction with a variety of other
defusion strategies. For example, a couple minutes of mindful attention
to the breath can better equip clients to engage more fully in some of
the more classic ACT exercises, such as the Physicalizing Exercise or the
Tin Can Monster Exercise (Hayes, Strosahl, & Wilson, 1999). (These
will probably be familiar to you if youre not very new to ACT. If you
are, please take a look at the Recommended Reading section at the end
of this volume.) Thoughts can be particularly difficult to notice without
getting hooked. Coaching focus on physical sensationslike focusing on
the minutiae of sounds or tactile sensations such as temperature or physical pressure (for example, the sensation of your clothes where they touch
your body) or focus on breathis somewhat simpler. Beginning with
these simpler mindfulness exercises before moving to trickier areas like
thoughts is likely to make mindful observation of thoughts in exercises
like Leaves on a Stream or on Placards in a Parade (Hayes et al., 1999)
more readily accomplished.

Mindfulness and Acceptance


As with defusion, mindfulness is, in some senses, intrinsically an
act of acceptance. However, when a client has particular psychological content that generates a narrow and inflexible repertoire, coaching
acceptance in a mindful state can be much more effective than coaching
acceptance without mindfulness. As a general rule, its worth including
even a brief mindful moment before asking a willingness or acceptance
question. I find that this comes fairly naturally to me in that when Im
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Mindfulness for Two

asking willingness and acceptance questions, I ask them at a point where


Ive allowed the magnitude of the question to sink in for myself. If Ive
encouraged the client to help me feel the grit and grain of her struggle,
feel the cost of it, feel the terror of letting go, Ill pause before asking just
as Id pause a moment before jumping from a cliff (it may well feel that
way for clients). I dont want to rush these questions, so I pause and let
all that ambivalence and longing fill in around us. I grow quiet. ThenI
ask my acceptance question.

Mindfulness and Contact with the Present Moment


Mindfulness is one of our most direct interventions to precipitate
being in the present moment. It also provides a teaching opportunity.
Having precipitated the experience of being in the present moment, its
worth using the moments that follow as an opportunity for discrimination training. When were very stuck in therapy, learning to discriminate
the difference between being in the present moment and not being there
can allow us to notice whether were present-moment focused or not.
I tend to be less interested in the logical distinction than in the experienced distinction. Metaphorically, what Im after here is that clients
will be able to say, Hey, that was green, wasnt it?! rather than to say,
Green is the result of combining blue and yellow. I recall a fellow in a
clinical trial years ago who understood Zen inside out but spent zero time
in the here and now.

Mindfulness and Self-as-Context


As with being in the present moment, mindfulness can be a powerful
way of precipitating the experience of a sense of self thats independent
of the contents of consciousness. Its worthwhile in extended mindfulness exercises to occasionally ask your client, As you notice your breath,
notice whos noticing that! The Observer Exercise from the original
ACT book (Hayes et al., 1999) is a good example of how to use mindful
noticing in order to precipitate a strong sense of self-as-context. Just by
following such an exercise, we may also find that its possible to reinforce
a therapeutic contract. Making an agreement with a client about the
purpose and direction of treatment right after doing such an exercise will
likely facilitate making an agreement with the person rather than the
persons story about himself.
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The Hexaflex Model and Mindfulness from an ACT Perspective

Mindfulness, Values, and Commitment


Once again, a poet captures in a few lines what the psychologist
writes a book about:
He who binds to himself a joy
Does the winged life destroy;
But he who kisses the joy as it flies
Lives in Eternitys sunrise.
William Blake, Eternity (1976, 135)
Values can provide a good focus within a mindfulness exercise.
Sometimes values provide such a goad to action, such a sense that we
must act, that we can lose appreciation for that which we value. For
example, sometimes our lives with our children become a rush from
one responsibility to the next. Occasionally, however, we happen upon
moments of pure appreciation. There are times when my youngest
daughters are playing together, just the two of them, without an ounce
of self-consciousness, no awareness that theyre being watched. In these
moments, I have a deep, deep sense of appreciation for the richness of
my life.
Sometimes in the midst of a mindfulness exercise where, by definition, youre engaged in appreciation rather than action, this rich sense
of values can emerge. Commitments to valued directions sometimes
emerge more readily as fully present, voluntary acts when made on the
heels of experiencing such mindful, in-the-moment appreciation of a relevant value.

THE PRESENT MOMENT AS ANTIDOTE FOR


NONACCEPTANCE AND FUSION
In the ACT model, we believe that a great deal of human suffering is generated by fusion and avoidance. As time goes by, Ive become increasingly
convinced that fusion and avoidance have a very, very hard time surviving the present moment. Even when a client is too agitated, worried, or
angry to make a formal mindfulness exercise practicable, sometimes just
slowing the client downpersistently, over and over againcan settle
her into the present moment. And with that presence, some degree of
acceptance and defusion often follow. We find ourselves there, in the
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Mindfulness for Two

room, with the client well met. Thats a place where possibilities are
born. We can give birth to that place in our moment-to-moment interactions with our clients.
Before we discuss the means by which we can learn to infuse our
conversations with mindfulness, well examine some technical aspects
of mindfulness in chapter 4. These aspects will be useful both in formal
mindfulness exercises, and, more central to this book, in the exercise of
a particular kind of conversation I call mindfulness for two.

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Chapter 4

Integrating Mindfulness
Work into ACT

Problems get hold of us from the moment we arise in the morning. What
will I eat? What time is it? When do I need to leave for work? What will
my first task be upon arriving there? What projects need finishing? What
meetings do I need to attend? Do I need to pick the kids up after work?
Are there piano lessons or soccer practice? Do I need to stop for groceries? What will I make for dinner? Problem solving is our most prevalent
mode of being. Its no coincidence that literature is filled with exhortations of carpe diem. We very often seem to be carried without much
awareness from one task to the next. And at what cost, this inattention?
Even figured against the events of our workaday livespicking up the
kids, doing the filing, raking the leavesmindlessness can be quite dear.
So what might the cost be of a lack of focused, present attention during
that rare hour each week we spend with a client? What details might
go unnoticed? What unproductive habits might be reinforced? What
opportunities might slip away?
In this chapter, well explore the ways in which mindfulness and
its lack can help and hinder the course of an ACT intervention. Well
examine technical aspects of mindfulness. Ill also provide some working
scripts you can use to facilitate and coach mindfulness. My hope,
though, is that these technical notes will help you develop the sensitivity and facility to construct your own exercises and mindful moments to
generally facilitate mindfulness for two.

Mindfulness for Two

MINDFULNESS, MINDLESSNESS, ORDINARY


CONVERSATIONS, AND ORDINARY LIFE
Sometimes life conspires to wake us from our sleep. Death of a Salesman
is a classic literary study that considers the possible endpoint of a life
filled with one task butted up against the next. The life of Willy Loman,
the salesman in the story, ends tragically. Willys son, Biff, speaks to his
father as if to rouse him:
Willy! I ran down eleven flights with a pen in my hand today.
And suddenly I stopped, do you hear me? And in the middle of
that office building, do you hear this? I stopped in the middle
of that building and I sawthe sky. I saw the things that I love
in this world. I saw the work and the food and the time to sit
and smoke. And, I looked at that pen and I said to myself, what
the hell am I grabbing this for? Why am I trying to become
what I dont want to be? What am I doing in an office making
a contemptuous, begging fool of myself, when all I want is out
there waiting for me the minute I say I know who I am! Why
cant I just say that, Willie? (Miller, 1967, 128)
Is Biff alone in this? Biff finds himself living a life disconnected from
his values. But even when were doing things that are consistent with our
values, were prone to lose a sense of appreciation for those values. How often
do work, marriage, and parenting occur for us as burdens? Disconnection
from values and from life is available at each and every moment.
This is certainly true walking into a session. We, along with our
clients, are carried into session by the pace of our day. The rapid succession of tasks and the often-frenzied pace at which we engage with them
can easily determine the tempo of our interactions with our clients
often to both their detriment and ours.
Mindfulness is a great way to start a session. Its a way to take intentional control of the pace and pitch of lifeat least during this time we
have set aside for our work. We want to ensure that we have the pace
rather than the pace having us. Moments of mindfulness are likewise
usefully interspersed in a session. A bit of mindfulness will slow us down
and slow our clients down. No matter what activity we plan for a session,
theres little doubt that focused, present attentionon both our part and
our clientswill be an asset.
Coming into a session were often busy. We may be thinking about
the last client, about the client were about to see, about the contents of
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Integrating Mindfulness Work into ACT

our last session with this client. Our minds fast-forward to what we might
accomplish with this session, about a colleague we need to speak to,
about some administrative detail, and so forth. Similarly, our clients may
be trying to remember what they did during last session. They may be
worrying about whether they did their session homework or even trying
to remember what those assignments were. They may still be caught in
the hustle and bustle of breaking away from some activity to come and
meet with us. However you look at it, there is abundant opportunity for
inattention and distraction offered up to our clients and to us before the
start of each session. Mindfulness is a way to disrupt these patterns of
distraction and bring us rapidly into the here and now.

WHAT WAS THAT?


Do you remember what I wrote in the prolegomenon, about what led me
to an interest in mindfulness in the first place? It was that I had a very
hard time listening carefully to my clients. Whether in conversations
with a client or in everyday social exchanges, all of us have had at least
some trouble with listening. This difficulty is in large part due to the fact
that, without active and focused attention, we can literally miss half or
more of what people say to us in a conversation. We want folks to follow
our vocal instructions, so we need to do things that keep people from
spacing out and going off on little head journeys while were speaking
to them. In ordinary conversation, we can listen to about half of what
people say and get by pretty well. Watch yourself while youre conversing
with someone, and notice that you can often anticipate whats coming.
Notice that you dont listen to every word. Notice also that while youre
not listening, youre somewhere elseplanning, pondering, or thinking,
perhaps, but somewhere else and often somewhen else. The same is true
of others. (Or maybe this is just meyipes! Is it just me? Heavens! I hope
it isnt just me! You know what I mean, dont you?)
Try this experiment: When speaking casually to another person, just
toss random words into your sentences. Dont change inflection or pace;
just drop them in like they belong there. People will often hear what fits
and not necessarily what you said. Likewise, people see what fits. Heres
a visual example:
Paris in the
the spring
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Mindfulness for Two

Right now, go to the bottom of this page and read the footnote.1

PLACEMENT OF MINDFULNESS IN
A SESSION
Since our sessions are essentially hour-long conversations, you can easily
see how much opportunity might be lost if half or more of the conversation in the room goes unnoticed. Integrating mindfulness into the session
is one of the best antidotes to this disconnected situation. But how and
where should you begin to introduce mindfulness into your work?
As I suggested above, dropping a small bit of mindfulness in at the
beginning of a session is a great idea. A brief mindfulness exercise prior
to experientially challenging exposure work is likely to facilitate greater
engagement with the distressing object or situation. Even two or three
minutes devoted to simply noticing the inflow and outflow of breath can
make an important difference. Tom Borkovecs work has been very suggestive in this regard. Tom has found that a bit of progressive muscle
relaxation prior to an exposure session causes the exposure to produce
better outcomes (Hazlett-Stevens & Borkovec, 2001).
This makes sense when you consider basic learning processes. We
learn better when were present than when were absent, distracted, or
preoccupied. Humans are great at being physically present but psychologically absent (several of my students have mentioned my capacity for
this). Exposure sessions are, like virtually all of the work we do in therapy,
opportunities to learn new behaviors. In particular, they are opportunities
to learn how to respond to distressing stimuli in new and, we hope, more
adaptive ways. The presence that the initial mindfulness work fosters
makes the goal of learning these new behaviors more easily attainable.
Another very good place for a mindful moment is when we find
ourselves or our clients working very hard. As a general rule, when
you find yourself in conflict, struggling, or exerting a lot of effort, a
mindful moment can help. Things capture our attention. Things we call
problems really capture our attention. Again, there are likely very good
evolutionary reasons for this: we remember very well from our days wandering the savanna that its better to miss lunch than to be lunch.
1
Without looking back, immediately write the words you just read
below. Then go to the footnote at the bottom of the last page in this chapter
(page 96).
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Integrating Mindfulness Work into ACT

The problem with problems, though, is that they become merely problems. Its the mereliness of our problems and struggles that damns us.
Our problems often insist that they must be dealt with right this moment!
And this insistence can cause us to lose all sense of everything else that
surrounds us. Such a sense of struggle and effort while sitting in a chair is
a sure sign that your mind is trying to keep you from being eaten. When
either you or your client gets into this situation, look carefully around the
room. If you dont see any bears, its probably safe and useful to stop for
a mindful moment. Just let the silence fill in around you and encourage
your client to do the same. Sometimes the most surprising things will
show up in those moments.
I originally started doing this pretty naturally. I wasnt really thinking
in terms of mindfulness. I was just stuck and confused, and I somehow
learned to shut up, sit still, and cease any effort when I didnt know what
else to do. I learned to wait. I learned to practice acceptance. I learned
to let my thoughts run on ahead. I promised them that I would catch up
later (but really I was just shining them on). As I write this, I feel a tug
inside that wants me to write you a list of complicated-sounding instructions about how to do this. But the truth is that I got there by just sitting
still for a while and giving my mind permission to take a short holiday.
It sounds almost too easy, and it can be. But remember that, in the
context of a mindful moment, just sitting still can and should be done
quite intentionally and explicitly. Try it in your practiceeither in your
consultation group or with a client. When you notice yourself getting
busy, ask the client if you can take just a moment to settle. Let the room
grow still for a couple minutes. Get present to something, anything in
the current environmentsound, temperature, muscle tension, or your
breath. When you find your attention coming back to the problem youre
struggling with, notice that, and return gently to whatever it is that youre
focused on. Take a moment. Let the world fill in around you. And then,
having settled, come gently back to the task.
Im often asked about correct placement of these mindful moments.
Really, its difficult to go wrong. Human avoidance is so ubiquitous that
stopping humans at just about any given moment will mean stopping
them when theyre running. I sometimes joke at workshops that I have
a fail-safe detector that can tell me whether a person is in need of a
mindful moment. I then feel the persons wrist. If I can detect a pulse,
the answer is yes. If you really want to get a direct sense of the ubiquity
and automaticity of human problem solving, try what is suggested in the
previous paragraph. You can even try it all by yourself. Ill even make it
formal in an exercise.
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EXERCISE: Just Sit Still


Simply stop reading at the end of this paragraph. Go find something that
you can use to keep time for three minutes. Start the timer, and let your
awareness come to rest on your breath. Let go of any problem solving
until the timer goes off. See what happens.

If you found yourself getting busy, welcome to the human race. Minds
hate unemployment. If theres nothing to do, theyre happy to generate
make-work projects. And they dont ask our permission when they do it.

QUALITIES OF MINDFULNESS EXERCISES


AND MINDFUL MOMENTS
So what qualities should you look for in your mindfulness exercises and
mindful moments? What states should you foster in your role as a therapist? A thorough list would be long indeed. And we could talk about
these qualities as either in the rooma positive indication of contact
with the present momentor not in the room, which would suggest a
lack of present-moment contact. Since the next two chapters are devoted
to recognizing breakdowns in present-moment contact during therapy
sessions on either your part or the part of your clients, lets spend some
time focusing just on the positive indicators of engagement with the
here and now. Again, there are a number of things we might choose to
look for: body language, eye contact, interactions with pens, watches, or
objects close to hand. But they call it talk therapy, right? Most of what
we do in the room is talking, so it seems as if the spoken word might be a
good place to look for evidence of mindfulness during our sessions. And
for our purposes here, lets focus on two aspects of our talking, namely
our voices and the content of what we have to say.

Voice
Your voice is a powerful instrument in your sessions and can be used
to dramatically alter the quality of what you get done in them. You might
think of your voice as the pipe through which your education, clinical
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experience, insight, and intuition flow to your client. No matter how


deep your understanding or keen your therapeutic instincts, if the pipe
is clogged, nothing gets through. If its too wide, the stream of what you
have to say will flow out too fast and wont be well absorbed. If the pipe
twists and turns and doubles back on itselfwell, lets not stretch the
metaphor too far, but you get the idea. Learning to use your voice well will
give you the best chance of bringing your hard-earned clinical prowess to
the fore in the service of your client. Ill break this discussion of voice into
three parts: tone and pitch, pacing, and the use of tempo and pauses.

TONE AND PITCH


I like to begin mindfulness work speaking in a soft, steady, deliberate voicesomething thats in the middle of my normal speaking pitch.
This matters because it gives me someplace to go pitch-wise as I proceed
with the work, varying my pitch in order to put emphasis on something
in particular. For example, I might ask a client doing a mindfulness exercise to notice the temperature of his hands.
Begin to notice the temperature of your hands [pause and notice].
See if you can notice that there is slight variation in that temperature
[pause and notice]. See if you can notice that one hand is just slightly
[with voice just a bit higher and a bit softer, like youre telling a
secret] warmer than the other hand [pause and notice]. See if you
can find the warmest place on your hand. See if you can notice any
tiny sensations that go along with that warmth [with voice a bit
higher and softerand then pause and notice]. See if you can
notice that, rightatthisverymoment [said with just a bit
more forceand then pause and notice].
Can you see how this works? It might be hard to grasp from the printed
page, which is one of the reasons we included the video sessions with this
book. Listening to my formal mindfulness inductions on those recordings
will give you a better idea of how you might use variations in pitch and
tone to facilitate great mindful presence with a client. In general, these
variations in tone on a backdrop of slow, soft, steady speech will continuously draw your client back to the exercise and into the present moment.

PACING
In short, go slow. How slow? My own guide is to pace mindfulness
exercises by actually following my own instruction. In the time it takes
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me to do what Im asking my clients or trainees to do, I can usually


assume that they, too, have had a chance to fully absorb the direction.
I typically have clients do mindfulness exercises with their eyes
closed, and I usually close my eyes while Im guiding them. I may let my
eyes drift open gently and then allow them to drift back closed, but I
generally keep them shut. Letting go of our dominant sense lends deliberateness to what were doing, and this tends to slow things down, in my
experience. If I try to guide an eyes-closed exercise with my eyes open, I
find that Im sort of set on a faster speed than my client. Following the
instruction I give tends to keep me operating at the same speed as the
rest of the room, whether it consists of one client, a practice group, or a
whole workshop.
You find useful material for guiding a mindfulness exercise in your
own engagement with the directions youre giving. If I say something
like Stop for a moment and notice your hands, I will then stop myself
and carefully notice various sensations in my hands. When I do, I often
notice different temperature sensations on my fingertips, my palms,
one my pulse points, and so forth. When I do, I might say, See if you
can notice that there are small variations in temperature on different
places on your hands. I would then spend another moment noticing
that myself. I might then feel a tingle in my right ring finger, whereupon
I might say, See if you notice tiny tingling sensations. Then I shut up
and try to notice any little tingles. Sound like cheating, doesnt it? But
this is really what youre trying to foster with these exercises: conscious,
nonjudgmental attention to things as they are in the here and now. My
typical instruction pattern looks something like this:

Notice
Speak
Then notice again, just a bit more mindfully
Then speak
Then notice
Speak again
Notice one more time
When I do this, I find that my pace works better for the clients than if
I think explicitly about how long to wait between instructions. I also find
that if my instructions come out of my experience, my pacing improves.
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The goal of mindfulness practice is to connect to your present-moment


experience, and this is ultimately what should inform your work. Even
if you use scripts from this book for your meditations, use them just as
guides. Read the meditation and get a sense of the general shape of it.
Then try doing the meditation. When you go on to use the mediations
with your clients, though, keep with the spirit of the thing by remembering to infuse it with your own experience of the moment.

VARYING PACE, TONE, AND PITCH


While a slow and steady pace is the backdrop for a mindfulness exercise, variations on that backdrop will serve to draw the clients attention
back to your voice and to the next bit of guidance. Both the soft, slow,
steady backdrop and the variations are important. Its the slow pacing
that gives depth to moments where the pace speeds up just a bit. Its the
soft backdrop that brings into relief the places where particular words are
given a bit more emphasis.

PAUSES AND TEMPO


A slow, deliberate pace makes an excellent backdrop for intentional
alterations of pacing. Think of this auditory backdrop as a primed canvas
or the bass line in a song. Its an anchor, a place to start from, a context
in which action can occur. It provides a backdrop that gives relief to the
variations we introduce. The more consistent the backbeat, the more
clearly we note the variations. We need this because in our daily conversations our attention drifts in and out, and the unexpected changes draw
our attention back to whats being said. When drifting has a cost, as it
does when we lose the thread of the conversation, we either work hard to
catch up or say something such as Excuse me, could you say that again?
You can short-circuit the habit of half listening by building in some variation on a backdrop of slow, deliberate pacing.
Variability in tempo is a good strategy. I will often putpauses
inwhere they dontbelong. This is a sort of antipunctuation. Dont build the pauses in where periods and commas would go. In
fact, theyre more effective dropped in places that would ordinarily flow
together. If you overdo this, youll annoy people. But a bit of unexpected
pausing helps to maintain attention.
Try this in ordinary conversation. Start to speak and then
pausein midsentence and watch the person youre speaking to attend more closely. Let your pauses draw out a bit. Throw in a
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few. The listener will hang on to the next word. I live in the South and
have heard some extraordinary African-American preachers. These
folks understand the potency of a well-placed pause. Listen to your
favorite music and notice how the pauses draw you forward into the
next phrase in the music. The rests in a piece of music are as important
as the notes. If you doubt this, I invite you to listen to one of those computerized greeting cards for half an hourthe ones that play Happy
Birthday or Jingle Bells in a piercing, computerized loop thats all
continuous music, with no rests or respites. If you do, I suspect youll
agree with me that the pauses between the notes add much-needed
interest to the sound.
How long should you pause? It depends. When Im guiding a mindfulness exercise, Im not in my head counting, Okay, elephant 1, elephant
2, elephant 3thats long enough. As for the general pacing of speech,
I measure the length of pauses by becoming a listener to my own words.
I hang a bit on my next word, listening for it for a moment. When I can
feel a bit of anticipation, I pause just a bit longer and then let the next
word drop. I hold these pauses as long as I can comfortably tolerateand
then I hold them just a little longer. I notice my urge to move ahead. I
will often comment on this urge: See if you can notice yourself trying
to move ahead in the exercise. Then I pause and notice myself longing
to push forward. Once again, the time I take to notice these impulses
to rush ahead will probably give my clients or trainees enough time to
do the same thing. Our natural inclination is most always to move more
quickly than is useful. As a general rule, slow down just a little more than
you think is enough.
A parallel concept to the pause in the spoken word is negative space
in the visual arts. Negative space is that space on the canvas or in the
sculpture that has nothing in it. Balancing positive and negative space
and playing with the two creates interest and draws attention. Novice
artists pay too much attention to positive space (the subject) and not
enough to negative space. Just as an example, in da Vincis painting The
Last Supper, the subjects are bunched together with the exception of
the space just to the right of Jesus. That small difference in spacing has
attracted enormous attention and speculation about the meaning of the
space. Whether or not you think there is any substance for the claimed
symbolism of the space, it is unquestionable that it has drawn extraordinary attention.
Consider the idea of negative space as you construct mindfulness
exercises and briefer mindful moments. A fairly organic way to introduce

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this into your mindfulness work is to take some time to appreciate negative space. Do mindfulness exercises with no one at all in the room.
Instruct your own attention to come to rest on something like your
breath. As you do so, introduce pauses into your speech and then linger a
moment over those pauses. Become interested in them. Attend to them.
Listen to them as if they had a secret they could tell you and then see
what happens. One thing thats likely to happen is that your mind wont
like the exercise. That is fine, and expected. Just persist and attend to
that negative space youre creating.

Practice, Practice, Practice


In order to learn more about tone, tempo, and pauses, do mindfulness exercises with your clients or practice group, or even by yourself.
If youre feeling very ambitious, record a few of your exercises and then
listen to them several times. Pay special attention to the qualities of your
voice and especially to those pauses. This sort of practice will improve
the aesthetics and fluency with which you use your voice, as well as that
space between your words, and a more fluent voice will mean a more
powerful and direct delivery of your clinical abilities to your clients.

THE CONTENT OF MINDFULNESS


The content of a mindfulness exercise can vary widely. Just look around
at the various schools and practices in the traditions from which mindfulness emerged: mantras, breathing, walking, sweeping, playing the flute
with a basket on your headthe list goes on. What this suggests is that
mindfulness can be effectively and usefully applied to a wide variety
of content. That said, some domains are easier to be mindful in than
others. Ive always found that becoming mindful of thoughts is the trickiest of tasks. Just noticing yourself thinking a thought is hard (at least for
a monkey mind like mine). In fact, most exercises that involve noticing
thoughts, like Leaves Floating on a Stream from the first ACT book
(Hayes et al., 1999), are used to show to what extent thoughts pull us in.
By contrast, its far easier to focus attention on a spot on the wall, on one
of the small sounds in the room, or on the breath.

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From Prominent to Minute


As a general strategy, moving from very prominent foci to subtler,
more specific, and detailed ones can serve to refine our attention and
to draw it into the present moment. Generally speaking, things as we
notice them are aggregations of still smaller things. If we pay close attention to larger and more complex (and thus more prominent) phenomena,
were likely to notice the smaller details that make them up. A good
example would be to notice the sounds in the therapy room. As part of
a mindfulness exercise, you might ask clients to imagine that they have
a mental checklist. Ask your clients to start with the most prominent
sound they can hearmaybe the buzz of an electric fan or the traffic
on the street outsideand check that one off. Then ask them to listen
for something slightly less prominent, some sound within the sounds of
the roomthe rustling leaves of a plant on which the fan is blowing, the
unique sound of tires on wet pavement outsideand check that off too.
Have them repeat this refinement until theyre listening to the tiniest
sound perceptibleperhaps the soft thrumming of their own pulse.
Or you can ask your clients to focus their attention on one prominent sound, like the heating or air conditioning. As they begin to focus,
ask them to notice that, within that sound, there are variationssofter
or louder sounds, higher or lower pitches, cycling from softer sounds to
louder ones, from higher pitches to lower ones. With attention, its possible to discriminate a great deal of detail within what might otherwise
just be called white noise.
The focus on different sensory aspects of the breath is perhaps the
most common meditative practice, in large part because the breath is
readily available. The breath contains a nice variety of sensory details
that can be used to draw a person into the present moment. From the
grosser perception of the alternation of inhaling and exhaling, you can
guide your clients to notice a host of subtler details in the breath:

The coolness at the back of the throat as air moves into the
lungs

The peculiar sensation of air coursing in through the nostrils


The rise and fall of the belly
The tightness in the chest as the lungs reach their full
capacity

The

warmth that rises in the back of the throat on


exhalation

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The list goes on. Deep and profound formal mindfulness practice
can center on awareness of the breath.
The same sort of winnowing of more prominent aspects of experience to more subtle ones can be done with tactile sensations. To guide
clients through this awareness exercise, begin by having them notice the
feel of their whole body as they sit in the chair. Then have them notice
the sensations of their feet touching the floor, the places where their body
touches the chair, and the places where their clothing touches their skin.
Have them further concentrate their attention by especially noticing the
marginsthe areas right at the very edge of where clothing touches and
does not touch. Guide them to notice the tiniest details of sensation that
tell them where their clothing touches and where it does not. Have them
trace the edge of these margins in their imagination as they notice the
sensory details along that transition between touching and not touching. These small details, which require a great deal of attention, assist in
bringing intentional, focused awareness to the present moment.

From Then to Now


Another method of focusing attention is to start with the stream of
activity that brought clients to session. Walk the clients through the time
prior to coming to sessionnoticing the activities of the day, going to
work, driving to the appointment. Ask them to let their attention touch
lightly on the things they were thinking and doing as they came to the
office, what they were thinking and doing as they sat in the waiting
room. Direct them to see themselves as they walked into the room and
came to rest in the chair, as they closed their eyes and finally found
themselves sitting right here, right now, in this very moment.
Here is a short script of what this might sound like. Remember that
this is just a guide. Your own experience will inform how this exercise
might sound in your own therapy room.

Stream of Activity Mindfulness Exercise Script


I would like for us to start with a mindfulness exercise to see what it is like to
stop and pay attention to the details of everyday life. These types of exercises
may help you get into the room, into the here and now, and to notice how
quickly thoughts take us away from experience. You cant learn unless you are
here inside the room.
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[Try to incorporate details of your clients activities, if you know


them, to make the experience more personal and relevantnames and
familiar places and situations would be helpful. Present this in a slow,
deliberate fashion with pausesgood long pauses. Use your volume,
tone, and prosody of speech to capture your clients attention.]
Just take a second to settle in. Just let yourself settle into your chair.
Let your eyes shut gently.
If you would, follow the sound of my voice, and if you find your mind
drifting, notice it and come back to the sound of my voice.
I want you to let your mind trace the steps you took to get here today.
[Pause.]
Picture that processgetting upthe routine of getting ready.
Notice it like youre watching a movie of yourself.
Maybe you had plenty of time or maybe you were in a hurry.
See if you can remember your concerns and thoughts as you were preparing to get herethings during the day you need to do.
Let yourself notice the busyness of that moment.
[Pause.]
Notice getting into the carmaking it herejust notice that.
Now, sort of push forward as you move toward getting here.
See if you can recall what your body felt like when getting herethe
places you passed byjust let it tick through your mind.
Picture yourself arriving hereat this building.
[Pause.]
Gently watch those interactions with others as you arrivedjust notice
each one. And finally notice settling into your chairwhere you find yourselfright now.
See if you can just imagine that the strands of activity that brought you
here today are some kind of fibers connected to you.
Just imagine that the strands that brought you here gently begin to drop
away with the inflow and outflow of your breath.
Just breathelet yourself continue to notice those strands dropping off
slowly until youre just sitting in your chair right now.
[Pause.]
Let yourself become aware of your body and your breath.
[Pause.]
Let yourself become aware of your hands and the place where they rest.
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eye.

Notice the place where they touch and the edges of those places.
See if you can trace the outline of that slight pressure with your minds

See that shape of each place where your hand touchesjust breathe.
See if you can begin to notice the tiniest sensations in your handsthe
smallest tinglesfeel the blood moving.
Draw your attention now to your breath.
Take three very gentle, full, mindful breaths.
Notice each small detail, where you notice the inflow and outflow of each
breath.
Now gently, gently let yourself come back into the room.
When you are ready, open your eyes.
Depending on how seriously you take the injunction to make your
pauses good and long, this exercise might take you anywhere between
five and ten minutes. Done with care and intention, it can really transform the feeling of the room and make space where good work can be
accomplished.

INTRODUCING MORE
CHALLENGING MATERIAL
Thoughts, memories, and emotional reactions can be good material
for mindfulness exercises, but beginning with sensory details and then
moving to these more challenging domains is often a good strategy. To
put it in technical terms, with some exceptions, sensations, sounds, and
so forth are likely to carry fewer verbal-evaluative functions and therefore are less likely to generate fusion and avoidance. In other words, the
awareness of the sensation of a chair on the back of the legs or the coolness of the breath on the upper lip are far less likely to be distressing to
a client than, say, evoking the thought of a hectoring boss, a moment of
trauma, or another lonely night spent despondent on the couch.
There are exceptions, of course. Noticing heart rate might be very
loaded for a person with a history of panic, yet for someone with no
panic history, focusing on the heartbeat can be a nice, quiet meditation.
Likewise, a person with a severe sexual abuse history might struggle with
body awareness, but perhaps less so with becoming aware of the variations in temperature of the hands.
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As a general guide, begin with a focus on events with a reasonably


low verbal-evaluative load. After establishing a mindful, focused state,
move on to more challenging material. Informed consent is a necessary
part of this work (and a subject covered thoroughly in other ACT books).
When materials are likely to be challenging for general reasons, like
thoughts, or specific reasons, like heart rate for someone with a panic
disorder, spend a bit of time making sure that the work youll do will
be done with permission. Also, in order to take advantage of the flexibility in responding produced by mindfulness, you should make a point
of moving gently and flexibly between difficult content and the breath
or some other more neutral focus. Dont mistake this shifting of focus
for avoidance of painful experience, though. The purpose of the return
to breath isnt to attenuate the intensity of the difficult content; rather,
its to remind us that theres more to the world than the hard things we
sometimes find in it.

VIOLATING CATEGORIES AS A WAY INTO


THE PRESENT MOMENT
The uncategorized world is a scary place. Humans love to make categories and to fit everything into them. If something doesnt fit in a category,
it goes into a category of things that dont fit (and we need to get those
things figured out right away). Categories are great. If you have insurance policies categorized as good ones and bad ones, you can pick a good
policy. If we have categories of routes home that are good and bad, we
can pick the best route. Categories also have a downside. They rob us
of the intimacy of immediate contact with our world. Our categories
often pull us out of the here and now of experience. We chunk the world
into categories, yet, like all representations, the categories should not be
conflated with that which they represent. Ren Magritte illustrates this
elegantly in La Trahison des Images (The Treachery of Images), his painting of a smoking pipe floating above the legend Cei nest pas une pipe
This is not a pipe. This seems cheeky at first, but if we think about it,
Magritte is clearly correct. The painting is ground pigment and oil dried
on a canvas in a convenient arrangement that evokes in many of our
minds the notion of the smoking article. Its most emphatically not a pipe.
In an important sense, all categories are lies. Sometimes theyre useful
lies, but its important to remember that the categories dont exhaust the
phenomena categorized.
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USING THE EDGES, MARGINS, AND SPACES


IN BETWEEN IN MINDFULNESS
One way to temporarily circumvent the minds insistent and persistent
categorization is to violate the rules of categorization. These violations
can pull us into the present moment. Ive had a very long love affair with
margins, with hesitations, with interstices, with the spaces in between.
When Im guiding someone to notice temperature variations in her
hands, I might ask her to notice the very edge of the sensation. I might
ask her to imagine that she can feel each individual cell and to allow
her attention to move from an area thats clearly warmer outward, cell
by cell, feeling her way to the edge of that variation, to that tiny margin
thats right in between warmer and cooler.
In another variation, I might tell a person that Im about to say some
words, and that Id like him to notice the space between the words. Then
I might roll back and forth over the words, allowing good long pauses
between them. I might ask the client to attend carefully to the fullness
and texture of that space between the words. You might try this with a
colleague or client, or try it on your own. Do this with significant words:
Im a father. I care about my body. Go very slowly, and do this repeatedly. The first few passes will be very noisy; your mind will complain.
First it will complain that theres no point. Then it will complain that
it gets the point, so theres no need to go on. Give your mind a kindly
pat on the head and stay with it. Listen for those spaces between words.
Persist and those spaces in between will fatten up psychologically. Really!
They will. Just persist.

MIXING CATEGORIES TO
DISRUPT CATEGORIES
Another way to disrupt the categorized world is to mix categories in ways
that violate the commonsense properties of the categoriesfor example,
give visual qualities to tactile events. Have your client close his eyes and
direct him to attend to his breath. After he settles a bit, ask him to
imagine that he can see his breath as you might on a very cold day. Ask
him to picture his swirling breath as it enters and leaves his body. Ask
him to let his breath take on colors, perhaps blues and greens on the cool
in-breath and oranges and reds on the warm out-breath.
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Many Gestalt-type imaginal exercises have this quality. These exercises often involve having a client visualize a difficult emotion, then give
color, shape, texture, temperature, and size to the emotion. In the next
chapter, where well discuss ways clients break contact with the present
moment and how to help them come back, well describe the ACT processes through which these sorts of exercises are thought to work and
offer detailed instructions on how to carry them out in the therapy room.
For the purposes of this chapter though, it will suffice to say that these
interventions disrupt the categorized world a bit and make contact with
the present moment more likely.

ASKING QUESTIONS DURING


MINDFULNESS EXERCISES
Although traditional mindfulness practice does not involve questions
and answers, the sort of exercises described here can often involve some
questions. When you need to ask questions, tell the client before the
exercise that you want very brief and minimal answers. Tell her that,
if you need more information, youll ask for it. Also tell her that she
shouldnt stop the exercise to answer. She shouldnt, for example, open
her eyes and talk with you as she might in a conversation. If the client
does stop the exercise to talk, gently coach her to close her eyes again,
use a few words to refocus her, and ask the question again. Again, well
talk more about this in chapter 5. For now, just note that mindfulness
work can contain questions, although they need to be handled delicately
and with some care.

INITIAL VS. LATER MINDFULNESS


EXERCISES
As is true generally with experiential exercises, there are individual differences and, within these, differences in individual learning curves.
Some clients will be able to participate in the exercises right away. For
others, it will be a struggle. Theyll find themselves moving in and out
of the exercise. As a rule, your clients will improve over time as a function of repetitionand so will you. The more consistently you do these
exercises, the better your clients will get at them. Early on the exercises
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will likely need to be longer, which might seem counterintuitive if you


have a formal meditation practice of your own in which sittings tend to
get longer and longer with greater skill. The exercises you do with your
clients early on will require more meticulous attention to detail as you
direct their attention to various sensory experiences. After they become
more adept, theyll be capable of moving with relative ease from ordinary
conversational modes into a relaxed, mindful, present-moment-focused
stateand so will you.

EYES CLOSED VS. EYES OPEN


Some clients have a difficult time closing their eyes. Ive seen this numerous times, for example, with individuals who have been victims of physical or sexual assault. If they do, ask them to cast their view down and to
allow their eyes to focus on a spot on the carpet. In doing so, we disrupt
the social and conversational aspects of the interaction by keeping the
visual focus on something other than the therapists face and posture (as
would be usual in most social interactions). Ask them to let their eyes
fall partway closed if theyre comfortable with that. You can often gently
coach such clients to close their eyes more and more over time. Bear
in mind that theres nothing magical about keeping your eyes closed.
Closed eyes simply reduce visual input and, importantly, significant nonverbal social input from the therapist. These minor variations on eyes
closed can accomplish the same thing.

TIME TO PUT DOWN THE BOOK AND GO


FOR A WALK OUTSIDE
You were so riveted that you plowed right from the introduction to this
point, right? Who could blame you? Technical behavior analysis and a
discussion of mindfulness processes is griping stuff. In truth, Im a little
shocked that no one has optioned the movie rights to this thingat
least they havent yet.
But seriously, this is more or less the halfway point of the book, even
if I havent filled up more than half of the pages. So far Ive described a
personal psychology thats grounded in the commonality and ubiquity of
human suffering, in the urge to problem solve, and in our dis-ease in the
face of ambiguitya psychology that is likewise grounded in a drive to
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Mindfulness for Two

seek liberation from these constricting forces for the purpose of allowing
us and our clients to live richly vivid and purposeful lives. Ive situated
this personal psychology within a theoretical framework, and Ive either
introduced you to or reacquainted you with some of the basic behavior
principles that can animate and enliven your work with clients. Ive connected ACT to the tradition of behaviorism, and situated the practice
of mindfulness centrally within the ACT process model. And finally,
Ive explored the mindfulness practices and shorter mindful moments,
proposing a technology of mindfulness that can be useful to you in your
clinical work.
So whats next? In the chapters that follow, well take a look at the
specific kinds of opportunities youll encounter in the therapy room for
fostering greater contact with the present moment through mindfulness.
Well also take a look at a field guide that will help you recognize
the telltale signs of mindlessness or a lack of contact with the present
moment in both your clients and you. Well dive into the wild world of
transdiagnostic, hexaflex-oriented case conceptualization. And finally,
Ill share some annotated scripts of several exercises for fostering greater
presence.
In the meantime, though, put the book down (even if you didnt read
straight to here, no ones watching.) Stretch your legs. Take a few deep
breaths. Get some coffee or go for a walk outside.
Whats going on in the world? Maybe the sun is setting or rising.
Maybe your kids are outside playing. Maybe someone you love is watching
TV in the next room. Maybe, even now, your clients are out there somewhere, doing the best they can to live their lives in a way that matters.
Before you go on to the rest of the book, take a moment to sit inside
this question: what is the reading Im doing here in the service of? Dont
struggle for an answer. Just linger in the question. When youre ready,
please join me in chapter 5.2

2
Look at what you wrote. Did you write, Paris in the spring? Now go
back to the text and notice that the word the is repeated in the sentence. This
is an example of the part-attention we often pay to the stream of words that pass
by us every day.
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Clients and the Present Moment

Chapters 5 and 6 work together to fulfill the ambition of this books


title; they develop a stepwise approach you can use to foster mindfulness
for two. In this chapter, were going to look at client presentations and
opportunities for growth. In chapter 6, it will be your turn as we shift our
focus to the therapist side of things. These chapters answer the questions
What does this stuff look like? and How do I do it? Built on the foundation laid in the first half of the book, what follows will give you a significant set of practical skills and approaches for integrating mindfulness
into your therapy sessions.

COMING TO THERAPY
From an ACT perspective, fusion and avoidance drive a tremendous array
of psychological difficulties. We began this book by taking a hard look at
the ubiquity of human suffering and at the flip side of that suffering
the ubiquity of human problem solving. Our clients come to us because
theyre suffering. Theyre suffering, and theyre also doing something else,
something very sensible. Theyre doing everything in their power to end
that suffering. From an ACT perspective, its not the suffering per se that
takes away from life as much as it is our propensity to resist suffering.
What we ask clients to do in ACT is to let go of wholly sensible attempts
to solve the fundamental problem of human suffering.

Mindfulness for Two

Why? Why should they let go of such an entirely sensible enterprise?


We ask them to do this because we believe that, if they stop struggling
for just a moment, theyll see the cost of the struggle stretched out across
their lives and the lives of those they love. And if they can bear that, for
just a moment theyll see precious things, rich and beautiful things, that
could fill their days. How do we slow them down enough so that they and
we can see this? We must meet them.

MEET YOUR CLIENT


If were to meet our clients, we must meet them where they are. Our
clients live inside stories about the world. I dont mean that the stories
arent true. Often they are. But the world is much richer than any story
about the world.
In ACT, theres an assumption that clients can navigate more effectively if theyre in better contact with the richness of the world around
them as opposed to the story about the world that their minds deliver to
them (and to us all). Whats the role of mindfulness in this contact? To
put a fine point on it, from an ACT perspective mindfulness is viewed
as the bringing of flexible yet focused attention to bear in the present
moment, and in a certain way:

With equanimity for that which is encountered


Noticing verbal presentation of the world in thoughts as
thoughts

And with all this done by a you that transcends the contents of consciousness

You might better recognize these three points by the handles we


commonly affix to them in ACT: acceptance, defusion, and self-ascontext. From an ACT perspective, with the exception of some situations involving relatively immediate harm, it is in mindfulness that we
are best prepared to meet the world, to notice what we value in it, and to
gently turn toward that which we value.
What keeps clients out of the present moment? From an ACT perspective, great suffering emerges from two major sources: fusion and
avoidance. Fusion with a story about the world tells us the limitations
inside which we must live. It tells us whats possible and whats not
possible. It tells us where pain was, where it is now, and where its likely
to be in the future. It tells us what we could do to prevent or attenuate
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pain and suffering. Experiential avoidance is a wholly sensible response


to a world construed in this way. What happens? We shrink from the
dangers of the world. We shrink from the unknown where danger might
bethe bear that might be crouching behind the blueberry bush. We
shrink our lives into something small and knowable. We shrink into
what Thoreau called lives of quiet desperation, what Eliot called lives
measured in coffee spoons. We shrink. We shrink, but theres really no
place to hide. Like cringing in the rain, we still get wet.

RECOGNIZE THE SMALL SPACES


CLIENTS INHABIT
If I could only offer one principle to organize your behavior, it would
be this: watch for narrowness and inflexibility in your clients behavior.
Narrowness and inflexibility are important, if you recall from chapter 2,
because theyre hallmarks of behavior under aversive controlanother
way of describing avoidanceand also hallmarks of behavior under
verbal control, which is to say, fusion. In what follows, well examine the
various forms this narrowness might take and ways you can help expand
the behavioral possibilities for your clients (and yourself) by contacting
the present moment more fully.

COMMON PATTERNS OF FUSION


AND AVOIDANCE AND FAILURES OF
PRESENT-MOMENT PROCESSES
In a certain sense, we can think of almost all forms of fusion and avoidance as failures of present-moment processes. Some of these patterns are
likely to emerge quite directly in your sessions. Chief among them are
worry and rumination, although there are others well examine, including storytelling, keeping conversations trivial, and others. These dont
exhaust failures of present-moment processes. For example, in chapter 7,
which explores experiential case conceptualization, well discuss inflexible planning and preparation as some other instances of the failure of
present-moment processes. Well wait to discuss these until later, though,
because theyre less likely to appear directly in session or to interfere with
present-moment processes in our sessions.
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Worry and Rumination


Rumination and worry have been connected to negative outcomes
in a large number of studies (e.g., Miranda & Nolen-Hoeksema, 2007;
Hughes, Alloy, & Cogswell, 2008). In many respects, rumination and
worry are two sides of the same coin, with rumination gazing back over
the past and worry looking out toward the future. Theyre alike in that
they both involve verbally grinding over a time thats not now. Worry and
rumination are examples of fusion because the storied version of events
dominates over the potential richness of experience. The dominance of
the storied version not only applies to the details of the events described
in the stories themselves, but also to the qualities of experience that are
present in the moments spent grinding over the story.
Please be clear, when I say story, I dont mean that the events
described in the story never happened. Consider, for example, an individual who ruminates over a childhood in which she was always the last
person chosen to play on school-yard sports teams. This person may go
over and over the story: I was too awkward. I was too shy. The other kids
were unkind. She may well have been shy and awkward, yet she was also
a child, a vulnerable human being, and lovely in her own right. But the
latter is likely lost in the midst of the former. Sometimes when stories are
true, they are even more troublesome. We put a lot of stock in truth, even
when engagement in ostensibly true stories takes us nowhere.
Worry, ruminations futurized twin, often shows the same unworkability. A socially anxious person may worry about how hell do in a social
situation. What if Im awkward or nervous or say the wrong thing? They
wont like me. Of course, a person with a long history of social anxiety
who has carefully avoided many, many social interactions is more likely
to be awkward and nervous and to say the wrong thing. The chances are
high that other, more socially skillful individuals will notice his social
deficiencies and respond accordingly. However, sitting at home worrying
about how social situations will go wont improve his social skills one iota.
The only way into the social game is to step into gatherings, exchanges,
and conversationsto guarantee exactly the poor performances that
hes engaged in fearing. The stories that are keeping him out of social
interactionswhether theyre far-fetched or as sure as Sundaywill all
have exactly the same impact on his social life, which is to cause it to
wither away and die.
In rumination, we grind over the past. We relive our history in
imagination. With worry, we relive feared futures over and over. As
behaviorists, we assume that this pattern of activity is functional. So our
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next question is how does it function? If we assume that rumination and


worry either produce something or promise to produce something positive, or reduce or promise to reduce something negative, what might that
be? First, lets look at what they promise to produce.

THE PROMISE OF RUMINATION AND WORRY


Lets look at some examples of worry and rumination and try to tease
out what their behavior function (or promise) might be.

Ruminating about what we (or others) said or did, or didnt say or


do. If you ordered the daily special at a local restaurant several times and
each time the meal was bad, you might come to the conclusion that the
special was something to be avoided. If you ended up on a dead-end street
while attempting to find a friends house, reviewing the route might help
you find out where you made the wrong turn, which could help you avoid
making the same mistake again. You might not spend much time reviewing a missed turn or a bad meal, but what if the cost of the past event
were greater than having to choke down some leathery chicken or arriving at a party ten minutes late? Perhaps you were betrayed by a lover, you
lost something precious to you, or you failed at a work endeavor. What
if the costs of these events were the loss of your marriage, the custody of
your child, or a job that you really enjoyed? It would make perfect sense
for you to want to be absolutely certain you fully understood the errors
that caused you to pay these high costs in your life. You might mull over
the daily special or the directions to the party for a few minutes; for more
consequential events, however, you might devote a significant portion of
your thoughts for the rest of your life. The promise of this sort of rumination is that it will prevent recurrence of significant negative events.
Self-recrimination about the past. We all have rich histories of punishment for misdeeds or even for poor performance. Delivering punishment
somehow sets the world right. In addition, we imagine that the punished
person is less likely to commit the bad act again. Its worth noting that the
supposed bad act need not be bad from the perspective of others. When
Cathy Freeman, the Olympic gold medal runner, retired from competitive
sports in 2006, she remarked, I have struggled with my motivation for so
long. I could no longer disguise from myself that I had simply had enough
My depression stemmed from the fact that I had come [in] a poor fifth, way
behind the world leader in my event, Ana Guevara, of Mexico, andyou
know what?I didnt feel distraught. However, from the interview it was
clear that she was quite distraught about not being distraught.
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Her comments are telling of the human condition. This remarkable


woman placed fifth among the fastest women in the world, and that was
a sign of poor motivation. Further, not remonstrating herself was itself an
additional flaw. I was visiting Australia at the time, doing some workshops,
when I saw the coverage of this event. As a father of daughters, I wept.
When you ask people what it would mean to let go of punishing themselves for past misdeeds, its altogether common for them to reply that the
punishment somehow keeps them in line. If they were to stop, nothing
could prevent them from being lazy, bad, unkind, foolish, and so forth.
Going over past misdeeds promises to keep unruly behaviors in line.

Worrying about the future. Worrying about the future is simply the
mirror image of rumination about the past. The worrier imagines scenes
and scenarios and all of the things that might go wrong. The promise
inherent in worry is that if we worry long enough and hard enough and
carefully enough, well be saved from these feared futures.
Worry and rumination to find reasons. Whenever something bad has
happened, theres a strong tendency to find fault or causea reason why.
The guilty must be exposed. Watch a movie, read a book, listen to a
story. Notice how unsatisfying it is when the story or book or movie ends,
and we have no idea who is at fault for the mishap around which the
story swirls. Another reason we strive so hard to find fault is that we live
in a culture that tells us that negative outcomes are often deserved. This
sensibility is so pervasive, there is even a generic name for it in social
psychology: the just world theory (Lerner, 1980). The just world theory is
derived from experimental findings in which people show a remarkable
tendency to believe that, when individuals experience bad outcomes,
they probably, somehow, had it coming to them. When we suffer some
negative outcome, we feel a strong urge to wonder what it is about us that
brought it on.
We like a coherent world, a world that makes sense. If we find ourselves in a bad way, theres a tremendous pull to come up with a reason.
Attributing the bad outcome to some personal flaw (specifically identified or not) at least gives some sense of resolution about why. We like to
know why. Think about how many times you or someone else has done
things after which you were left wondering why. Why did my relationship
go bad? Why am I so stingy? Why dont I ever get a break? Grinding over
such questions again and again can become a lifes work.
If we look at workaday events in the world, well find that searching
for reasons why is often quite useful. If your airline ticket is extremely
expensive and you do some investigation, you might find that traveling
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on a Wednesday is far less expensive than traveling on a Monday. The


next time, you might plan your trip accordingly. If the police examine
a crime scene, they might find a perpetrator, who might then be apprehended and incarcerated, and we might all be a little safer. If your checkbook doesnt balance, you might go carefully over each entry until you
find the error. In the end, you might discover why the checkbook hasnt
balanced and more importantly, what your available balance actually is.
When applied to transactional events in the world, an understanding of
causes and effects gives us great power to steer our lives in the directions
we would prefer.
But lets look at some questions that are a little more meaningful
and perhaps a little more personaland certainly a lot more complex.
Why do relationships never work out for me? How did I end up in this
dead-end job? Or, better still, why am I so depressed? Or anxious? Why
didnt I say yes when I really didnt want to do it? Why do I keep drinking? It doesnt take many hours in the therapy room to see that people
can spend their whole lives asking questions like these over and over
again. And often, having failed to come to any resolution, they attempt
to co-opt the therapist into the task.
But try to intervene in the story. See if you can move it around.
Reinterpret it. See if you can come up with a piece of contrary evidence
that cannot be offset. If its not impossible, its likely to be very, very
hard. If a person is easily moved from such a conversation, we wouldnt
be hearing about it in therapy. In situation like this, where refutation
and counterargument just lead to more wheel spinningmore worry and
ruminationa moment of mindfulness just might allow the client to
find a spot, just one lingering moment, where she can rest.

THE IMMEDIATE BENEFITS OF RUMINATION


AND WORRY
Rumination and worry both promise to deliver a better future, but
they also deliver something in the here and now. Theres a reinforcer
intrinsic to engagement in the pattern of activity itself. What does it
keep at bay? In the face of uncertainty and risk, vigilance is its own
reward. Worry and rumination, thus conceived, are a form of problem
solving. In problem-solving mode, we can at least maintain the illusion
that were doing something productive. Theres comfort in that. What
worry and rumination also do is take us out of the moment were in. If
being in our own skin is a very hard place to be, anywhere else could
potentially be more comfortable. Were used to thinking of methods of
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escape from pain as being pleasantdrugs and alcohol, for example.


Why would anyone escape to a difficult place? Self-harming clients are
a grim reminder that escape need only to be relatively more pleasant. If
the pain of being present is great enough, worry and rumination, though
terrifically painful themselves, can be good places to hide.

Storytelling
Our clients dont live in the world directly. None of us really do. We
live in a storied version of the worlda world modeled by the savanna
minds of our distant ancestors, shaped by countless generations of constant fear that we might either starve to death or be devoured by something with sharper claws and stronger jaws than we might ever hope to
possess. Its just a story.
Of course, storytelling isnt a bad thing in and of itself. Youve probably
guessed by now that I love a good story. But theres a version of storytelling
thats indicative of a failure of present-moment processes. I raise this here
because it will appear in session and directly interfere with just about any
intervention you might hope to provide. Storytelling can take a lot of different forms. The invariant and inflexible quality of this sort of storytelling
is the feature that youll want to learn to recognize and work with.
There are several versions of storytelling. Sometimes the stories will
be about negative instances in a clients history that are raised again
and again. These are in-session instances of rumination. Sometimes
the stories will be very proximal and wont involve repetition of longpast personal history. Instead the client may insist on a mind-numbing,
moment-by-moment recounting of every difficulty that occurred in the
past week. In this recounting, the client lists the problems in hope that if
the problems are delivered comprehensively and in enough detail, youll
be co-opted into joining him in the problem-solving task.
Unfortunately, this latter kind of storytelling can, at least initially,
be compelling to us as therapists. In the rehashing of this list of events,
we may be able to find something we can work on. But over time, this
pattern is wearying. There seems to be a never-ending supply of problems. Probably the best indicator of this kind of storytelling pattern is
when we, as therapists, find ourselves wrestling with incredible feelings of
boredom and frustration. (In chapter 6, Ill discuss some ways of dealing
with these, our own failures of present-moment processes.) As with rumination and worry, this pattern brings some relief to the client because he
at least feels as if hes working hard.
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Another variation of storytelling involves the repetitive description


of a better time. This sort of reliving in story has several appetitive functions for the client. It may provide her with a sort of euphoric recall. It
may also reassure her that something positive is possible, or at least has
been possible before. She may find some relief in the hope that she will
eventually find her way back to that better somewhen else. Such stories
may also serve a social function for the client with respect to the therapista way of saying, See, I havent always been such a mess. Theres
more to me than these problems.
A final storytelling form worthy of mention is keeping the conversation trivial. A conversation filled to the brim with trivialities has no
room for more profound (and more frightening) conversations. Variations
on this might include talking about the news, sporting events, or the
weather. This is the sort of conversation likely to leave you wondering,
Why is this person here? The casual quality of the conversation is
belied, though, by the ways in which your client systematically obstructs
all of your attempts to switch to a more significant conversation. In this
and all of the cases of avoidant storytelling, that is present-moment
process defeating, keep an eye out for any sort of conversation that has
narrow and inflexible qualities.

Apologizing
A last indicator of the failure of present-moment processes commonly
seen in session is persistent apologizing. Its ironic that clients come to
therapy and apologize for having difficulties, yet we observe it all the
time. When clients persistently feel the need to apologizefor interrupting you, for being upset, for forgetting to do homeworkits likely that
theyre monitoring their relationship with you very carefully. Persistent
apologies may function to ward off anticipated rejection. To get a sense
of the narrowness of this pattern, try pointing it out. The most common
response will be to apologize for the apologies.

MINDFULNESS, MINDINESS, AND


PRESENT MOMENT
In chapter 3, I suggested that theres an inverse relationship between being
in the present moment on the one hand and fusion and avoidance on
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the other. One sure sign than clients are slipping away from the present
moment is the emergence of what I playfully call mind-y conversations. Mind-y conversations are those conversations our clients have with
others (including us) and with themselves that contain a lot of fusion
and avoidance. You can become skilled at recognizing mind-y conversations and how to intervene in them. In the next chapter, well look at
the ways these mind-y conversations can hook you and the work you can
do to open up this bit of inflexibility. For now, lets examine the kinds
of things you can watch for in your conversations with clients that can
indicate mindiness.

How to Detect a Mind-y Conversation


We have mind-y conversations with our clients, and theyre constantly
having mind-y conversations with themselves. Mind-y conversations have
very particular qualities: comparison and evaluation; complexity, busyness,
and confusion; statements conjoined with but; adversarial posturing
and side taking; strong future or past orientation; strong problem-solving
orientation; strong focus on what something means about the client with
respect to others; explanation vs. description; categories vs. specifics; and
the familiar. Lets take a look at each of these qualities now.

COMPARISON AND EVALUATION


Mind-y conversations invariably compare (often dissimilar) things,
make evaluations, and level judgments: this thing, person, situation,
time, or place is better or worse than that other thing, person, situation,
time, or place.

COMPLEXITY, BUSYNESS, AND CONFUSION


Even direct, present conversations can be complicated, but mind-y
conversations can be positively labyrinthine, going every which way
and doubling back over ground already covered. In addition, mind-y
conversations often contain a demand that the complexity be solved
before life can improve.
Why did this relationship not work out? Maybe I should have been more
attentive. But then, it seemed like I was being attentive. And when I
was particularly attentive, she seemed to get mad. But maybe it was
the wrong kind of attentive. Maybe I was smothering her. I just never
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learned how to be with anyone. But how can I learn that if I cant keep
a partner? Maybe shell take me backgive me another chance. But
even if she does, I dont know what to do different. But if I dont try, it
will never work. But I dont know what to do.
So the conversation goes, ad infinitum. Sound familiar?

STATEMENTS CONJOINED WITH BUT


When looking for this and other aspects of mind-y conversations,
its worth listening for the word but. Etymologically, but comes from
a contraction of the verb be and the word out. Statements that are
introduced with but may quite literally be thought of as asserting be
out that, where that is the material that follows. There is a demand for
resolution inherent in the verbal formulation If I dont try, it will never
work, [be-out] I dont know what to do.
I dont know what to do has to go away before I can try. Our minds
give us this formulation as surely as an apple falls to the ground when
dropped. Sometimes weve talked about ACT as a treatment that gets
people off their buts. You might be tempted to refute the immutability
of the conclusion arrived at by a but formulation. There are a lot of
treatments that have worked on that basis. Youre welcome to try it. But
if the conversation is grounded fusion and avoidance, I predict that any
refutation you come up with will produce either mere compliance on the
part of your client or more of the same mind-y conversation. Either way,
youll still be disconnected from the present moment, and your progress
with be impeded.

ADVERSARIAL POSTURING AND SIDE TAKING


Mind-y conversations will often have an adversarial quality. You
can hear some the adversarial quality in the conversation above, about
whether or not the client could sustain a relationship. The argument
that hypothetical client was having with himself could easily have been
between him and his partner, and the dialogue might not have been
much different.

Joe:

Why didnt this relationship work out?

Judy: Maybe you should have been more attentive.


Joe: It seemed like I was being attentive. And when I was
particularly attentive, you got mad at me.

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Mindfulness for Two

Judy: Maybe it was the wrong kind of attentive. You were


smothering me.

Joe:

I just never learned how to be with anyone.

Judy: You never will learn if you cant keep a partner.


Joe:

Wont you take me backgive me another chance?

Judy: Even if I did, what would you do differently?


Joe:

If we dont try, it will never work.

Judy: But what would be different?


Joe:

I dont know.

If a client is locked in an adversarial conversation, avoid being drawn


into it. Whatever position you take, youre likely to fail. After all, your
client has mostly been having this conversation inside his head and has
far more practice at both sides of the conversation than you!

STRONG FUTURE OR PAST ORIENTATION


Mind-y conversations are usually littered with either warnings about
the future or reprimands about the past. Sometimes the warnings are
only implicit. If you listen hard and ask the right sort of questions, you
can hear the warning lurking behind what is said.

Client: I thought I was going to start crying right there in the


staff meeting. I cant look weak at work.

Therapist: Help me to understand whats at stake. Imagine for

just a moment that you broke down crying. Then what


would happen?

Client: Well, they would see how weak I am.


Therapist: And then what would happen?
Client:

I just couldnt do that! It cant happen!

Therapist: Sure, I understand. Im not asking you to have that

happen. And Im not saying its a good idea to let it


happen. Im just trying to see clearly whats at stake
for you here. You dont have to actually cry in a staff
meeting. Just imagine what it would be like.

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Clients and the Present Moment

Client: Its crazy. I dont even know why I was so upset. It


doesnt make sense.

Therapist: Sure. Okay. Just close your eyes for a moment and let

yourself see that room. Hear those voices. And imagine


that the tears just start streaming down your face. What
happens next?

Client: Well, everyone is looking at me. God, this is awful. I

cant believe Im doing this again! Why does this bother


me so much?

Therapist: Okay, now. Slow down. And breathe. And lets just

stop there a momentas if you could stop time. And


just breathegently, gently. And as you breathe, let
your eyes travel across those faces. Let it be as if, in this
moment outside of time, you can look at them without
them seeing that youre doing that. Imagine letting your
eyes rest gently on each facelingeringthen moving
to the next. What do you see?

Client: I see pity in their eyes. They think Im weak. I feel so


ashamed.

Therapist: Okay. And breathe. Can I ask you to just stay with this

another minute? And breathebreathegently, gently.


So they think youre weak. And what do they want to
do with you?

Client: They want me to leave. Im too much.


Just on the other side of I cant look weak is a warning about the
future. Listen for words like must, should, cant, and have to, all
of which point to the future. Listen and inquire for have tos and consequences. I have always thought that some of the genius of Albert Ellis
was his interest in shoulds and musts (and their cousins, shouldnts
and cants).
Conversations like this are often also filled with reprimands both
explicit and implicit. You can hear in the dialogue above the selfcontempt for weakness. These conversations provide the illusion of doing
something about the problemwarnings to forestall future failures,
reprimands over past failures to make those failures less likely to happen
again. But where do these conversations go? Do they actually take the
client anywhere at all?
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STRONG PROBLEM-SOLVING ORIENTATION


These conversations will often have the strong flavor of problem
solving. The content will present itself as a problem requiring resolution
right now, before anything significant can move forward. This is particularly suspicious since the so-called problem being solved has often been
hanging around unsolved for a very, very long time.

STRONG FOCUS ON WHAT SOMETHING MEANS


ABOUT THE CLIENT WITH RESPECT TO OTHERS
Not all values are connected to our relationships, but many, many
are. And since values and vulnerabilities are poured from the same vessel,
issues that touch on our relationships with others are fertile ground for
fusion and avoidance. Mind-y conversations often focus on what something means about a client in relationship to others or what others will
think about the client as a result of whatever the client perceives as the
problem. Listen for content that has to do not only with the nominal
problem but also with the implications that problem might have for
relationships.
If you want to see how this works, check it out using your most precious story about whats wrong with you.

EXERCISE: Whats Wrong with Me?


Take a moment and think about the thing you least like about yourself.
Read the following statementsslowly, carefully, lingering over each.
Read them aloud. See if you can notice some small (or maybe not small)
seeds of each in you. As you speak each one, allow yourself to own it
for a moment. Notice what shows up when you say it. What thoughts,
memories, and bodily sensations come up? Notice how much youre ready
to move on to the next item on the list or to skip this exercise altogether.
Before you even begin, see if you dont have a bit of Not right now, or
Sure, I get the point, or I dont get the point. Notice if your mind is
trying hard to get you to run the other way. Note that getting the point
is not the point, though. Making contact, getting present, having the
capacity to sit in hard places when sitting in hard places could make a
differencethats the point. So I invite you to do just that.

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Im selfish. I act like I care about a lot of things, but really


I dont.

Im needy. A lot of people dont really see it, but I live and

die on their criticism and praise. Ill do just about anything


to get people to like me. I cant believe some of the things
Ive done.

Im not really very smart. People think Im pretty smart, but


really, I work very, very hard and just barely keep up with
everyone else.

Im secretly jealous of others. I get mad when good things


happen for other people. I never say anything to them, but
sometimes I say things behind their backs.

I just have to have the last word. It has cost me a lot over the
years, but I just cant seem to keep my mouth shut.

Im lazy. Mostly people dont notice, but when they arent


looking, I get almost nothing done. Im a lump.

Im a coward, a doormat. I let people walk all over me. I get


mad, but I never say a word.

Im unlovable. Ive had relationships, but eventually people


get to see the real me and they leave. Sometimes Im hopeful,
but really I know that its just a matter of time.

Deep down, theres something missing from me. Ive never


been sure what. I look around and other people seem fine.
But me? Its like theres a hole.

Im fragile.
Im bossy.
Im ugly.
Im boring.
Im mean.
Im impatient.
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What is it thats wrong with you? Pause and just spend a moment
inside that question. Whats wrong with you? Being weak means being
shunned. Being stupid means being shunned. Being inadequate, boring,
ugly, lazy, jealous, and so forth meanswhat? In the end, these all have
implications for our relationships, for the possibility of relationships, for
the future of our relationships. And all we need to do is look at our past
for that evidence.

What does it mean to our clientsto all of usto live our lives
under this kind of burden?

EXPLANATION VS. DESCRIPTION


A common variation of the mind-y conversation is the explanation.
Its worth distinguishing two very different functions of explanation.
One variant of explanation is really just description. The other involves
description but contains a subtext of social evaluation.
To give an example, I might explain the life cycle of the frog
from egg to pollywog, the metamorphosis into a frog, and so on. Theres
nothing particularly socially meaningful about this explanation. Some
explanations, though, include an important social exchange. If I treated
my spouse with jealousy and distrust and caused problems in my marriage, you might think I was a bad husband. If I went on to describe a
horrific history of abuse in my own formative relationships and also to
explain all of the very good things I do in my marriage, it might mitigate
how you perceive me. You might take a more forgiving view of my behavior. My explanation might describe to you the details of my formative
years and my married life, but functionally it would also seek to alter
the relationship I have with you and likely the one I have with myself as
well.
When youre talking with a client, listen for subtexts that seem to
request a social get-out-of-jail card, your implicit or explicit approval
of whatever the client has done. Notice if you find yourself inclined to
respond, Oh, okay, I understand. Anyone would behave that way given
the situation. I can see that youre not all bad. Or, by contrast, you may
feel an urge to retort, Are you kidding! Do you think that excuses your
behavior?
Youre a well-trained clinician, so its not likely youd say either out
loud. See if you can notice, though, when a client asks of you something
in the way of evaluation or possibly approval. These conversations mask
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themselves as description but contain a request for a social pass. Sadly,


the request is foredoomed. In the case I describe above, the one about
my marriage, neither your blame nor praise will mend my relationship
with my wife. At best, you can provide me with a balm that will numb
me enough to persist in this line for a little while. But the conversation
will have only a modest sense of vitality and little means to effect valued
living.

CATEGORIES VS. SPECIFICS


Early in his career, Mark Williams did some lovely research in which
he found that depressed individuals produced more categorical rather
than specific memories as compared to nondepressed control subjects
(Williams & Scott, 1988). Mind-y conversations tend to be far more categorical than specific. Aaron Beck had a tremendous sensitivity to this
issue, although he didnt describe it specifically in these terms. Becks
cognitive errors are largely a checklist of varieties of categorical thinking. Overgeneralization, black and white thinking, and catastrophizing,
for example, are all examples of categorical thinking. Even when specifics are described, theyre quickly rolled into categoriesnever, always,
hopeless, and unbearable become fused categories that must themselves
be managed somehow.

THE FAMILIAR (AKA THE OLD AND STINKY)


The last of these common factors in mind-y conversations is that
theyre frequently familiar in the extreme. If any of the above resonated
with you at all, consider how long those conversations have been rumbling around in your head. There can be an endless repetitive quality to
these conversations.

GETTING PAST CONTENT


The contents of mind-y conversations can be very compelling. Its worth
noticing how much we want to either join in these conversationstaking
one side or the otheror run away from them. (Both getting involved
in mind-y conversations and fleeing them are, by the way, different topographical versions of the same response.) Can you think of times when
youve engaged in either response? Was it helpful? In my own experience,
I cant remember a time when it was. Instead youll probably find it useful
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to let go of the words in a mind-y conversation for a moment and just


listen intently to the physical qualitiesthe tone, pace, posture, and so
forththat the conversation presents.

The Quality of Speech in Conversations


Words are incredibly captivating. In ACT, we call this capturing of
attention fusion. Its neither bad nor good. But fusion can sometimes cost
us awareness of other things that are going on in our interactions with
clients. Clients come to us with problems, and our part in the conversation is to discover the nature of the problem and to generate a solution.
We typically go about this in a way thats not a lot different from ordinary
conversation, except that its typically more systematic. Were trained to
query some set of signs and symptoms. Is the person anxious? How long
has this been going on? Are there situations that make it better or worse?
On down the list we go. About the only time were trained to direct our
attention to the process of speech is when were assessing for things like
thought disorder.
The way ordinary conversation works is that one person speaks and
then the next person respondsback and forth we go. Watch yourself
in ordinary conversations. We devote a certain amount of attention to
the content of our conversational partner. Perhaps we try to work out
where hes going in the conversation. We devote the rest of our attention
to generating a sensible response. Clinical conversations often proceed
in the same way as ordinary conversations, except that we, the clinicians, bear the added burden of figuring out the nature and source of our
clients problems.
One of the main things I do when consulting on clinical work is to
slow therapists down, to get them to let go of the content of what their
clients have to say and see if they can hear something in the pace, pitch,
and cadence of speech.
Sometimes during experiential role play exercises at workshops, I
listen to the room. Its a good way to learn about the process of speaking
because there are dozens of voices in the room, and its almost impossible for me to hear the exact content being spoken. I direct my attention
instead to the process of speakinglistening for highs and lows, for the
rise of pace, for tone of voice, for the fluidity of speech.
I encourage you to try this yourself. Start listening to some of the
rooms you inhabit. While at lunch, let your eyes go closed and listen to
the restaurant. Let your attention move among the different sounds: the
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droning of the air-conditioning system, the clatter of the kitchen, the


overall sound of the voices. Notice the most prominent sounds. Let your
attention touch down lightly on the smallest sounds in the room. Listen
to the space between the sounds. See if you can appreciate the sound of
the room as a whole, as if it were a living thing. See if you can notice
how different sounds protrude and poke at the edges of that whole. Are
there rhythms, pulsings, repetitions? Do some sounds crowd others? Do
some seem to intrude from without? Do some draw your attention away
to some other task, to the past, to the future?
Notice how your attention is drawn to individual voices and to what
theyre saying. Notice to what extent youre drawn to the content of
speech, stretching out to pick up even an individual word. Our minds
are hungry for those words, for that content. Appreciating the whole is
not a job the mind will like. Its too simple. The categorizing will satisfy it
for a bit: dishes clattering, person speaking, door opening, and so on. But
appreciating the soundscape of the room as a wholetheres no problem
to solve! Whats a mind to do? Mmmcontent. Delicious!
Given even a tiny bit of content, the mind can start to figure out
whats being said. Figuring out is a task worthy of the mind. As you
notice yourself being drawn to content, see if you can gently let go of
that content and notice how your experience of the whole room changed
as you recognized words or sentences. Content can be like that. Once
we get it, even a snippet of it, content focuses our attention and the
wholeness of the experience drops away. When it does, let go just a bit
more and come back to the room as a whole. Just appreciate the shape
of the sounds in that room. Try this at staff meetings. Stop a moment in
line at the grocery store. Try this in a place that seems quiet and notice
that even those quiet places have their own subtle soundscape. Practice.
Practice that gentle return to the whole.
All of this practice, though interesting and lovely in its own way,
is intended to help you achieve a certain sort of conversation: mindfulness for two. Slowing down and listening in this way will take you out
of the stream of ordinary conversation. Ordinary conversational modes
are strong and well-rehearsed behaviors, and were very likely to become
absorbed in content when we engage in them. When we interact with
one voice, that of the client, content is even more likely to capture our
attention. Note that the goal here is not merely to ignore content, certainly not by force of will. The thing to work toward is an appreciation
of content in its place within the whole rather than having it substitute
for the wholealong with the ability to discriminate whats going on in
conversation beyond content.
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Recognizing Vocal Patterns


Sometimes the easiest way to hear your clients patterning and your
own is to listen to a recording of one of your sessions. This helps because
it takes the social cues for response off the table. Youll find it useful to
develop an ear for speech as process at the level of the individual speaker
and of the interaction between two individuals in conversation. Pitch,
pace, and cadence are always running in the background. They organize
content, but they typically go unnoticed or at least unappreciated.
Youll want to get an ear for the flow and texture of speech so that
you can listen for the emergence of patterns common in behavior under
aversive controlpatterns that are relatively narrow, relatively inflexible,
and relatively insensitive to contextual control. In order to hear variation
in vocal patterns, youll need to acquire an ear for patterning independent of content. Almost the only people who have such an ear are voice
instructors and musicians, though sometimes preachers and other orators
develop this capacity for hearing. Most of us leave this capacity undeveloped as we content ourselves with the content of what we hear.

LISTEN FOR VOICE QUALITY


Start your journey into the non-content side of speech by listening
for the relative fluidity of speech. Sometimes voice has a soft and pliable
quality. Sometimes it seems to have sharp edges. There is, of course, variability among clients, but youll hear variability within individuals too.
Listen for a strained, constricted, choked quality of voice. If the person is
being squeezed into a relatively narrow pattern of behavior, youll often
hear that reflected in her voice.
Youll also recognize urgency in peoples voices. It may sound like
pleading, whining, complaining, demanding, or being pressured. All of
these variations will share a certain imperative quality. Theres something, perhaps ambiguous, that must be done, solved, figured out before
anything else can happen. If youre focused on content, you are very
likely to miss this urgency. But you might hear it in someones voice if hes
speaking in a foreign language, an experience Ive had more than once.

LISTEN FOR PACE


Listen for your clients pace in casual conversation. Note the quality
of the patter in the waiting room, in the causal beginnings and endings
of session. Whats your clients pace when the conversation is easy? How
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does it change when the topic gets hard? Listen for patterns in pace that
might be indicative of a response to threat. Sometimes this will take the
form of an almost staccato series of complaints.
Your clients may at times proceed at a pace thats almost tentative.
They may speak in partial sentences or with long hesitations. Another
common pattern in pacing is a somewhat rapid pace, as if the conversation is urgently attempting to get somewhere or away from something.

LISTEN FOR CADENCE


And finally, listen for the cadence of a clients speech. You can practice this most easily with an audio recording. On your own, listen to the
recording and see if you cant duplicate the cadence without using any
words, just sounds. Okay, you will feel goofy doing this, but take a couple
of different client recordings and see if you can hum two distinctly different songsa bit like humming a tune. You can also try just tapping your
hand or foot as if youre tapping along to a song. See if you can notice a
patterning in that cadence.

REPETITIONS IN CONTENT
As I mentioned in the section above on mind-y conversations, youll
often find content that will be repeated again and again in session. Watch
for the emergence and reemergence of these topics and patterns of speech.
Watch for the relative inflexibility of these patterns once they emerge.

Recognizing Patterns in Physical Presence


Breath typically goes unnoticed. But breath is a physiological function thats quite responsive to conditions of abundance on the one hand
and conditions involving threat and ambiguity on the other. Is breath
smooth, slow, and regular? Does the client stop breathing at all during
certain moments? Does breath come in gasps? Does the person cough? Is
breath choked or constrained in any way? Is it deep or shallow?

REPETITIVE MOVEMENTS
Watch for things like nail-biting, hand-wringing, shifting in the chair,
fidgeting, foot tapping, clenching of jaws, and other small behavioral
stereotypies. Are there times when these are more pronounced, intense,
or driven?
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POSTURE
Often when people are in the throes of strong negative emotion, their
gaze will be downcast, shoulders hunched, and arms and legs crossed and
held close. There are a lot of social contingencies that cause people to
disguise and otherwise downplay the experience of negative emotion.
One way to accomplish this is to get small or to turn away slightly. Gaze
in particular is socially relevant. The social convention when weeping is
often for them to look away, to apologize, and, as quickly as possible, to
attempt to contain that display.

WATCH THE EYES


The poets say that the eyes are the mirrors of the soul. Its much
easier to manage what one does with ones feet and hands than with facial
expression of emotion. This is especially true of the eyes. Sometimes the
most transient touch of emotion will move across a persons eyes while
little else makes emotion apparent. A momentary watering of the eyes,
a slight heightening of reflectivity, may be the only apparent trace of
emotion you can see. You neednt know what has elicited the reaction to
see that the reaction has occurred. A simple slowing down around such
moments can sometimes reveal both to you and to your client the depth
of experience that underlies that upwelling.

Emotional Tone
Note the emotional tone the client brings to the session. Most frequently the emotional tone will have an anxious or depressive quality.
But its also not uncommon to see an overly casual presentationsort of
an Im fine posture. The critical issue for you to pay attention to is not
the tone as such, but instead the pattern and the relative flexibility you
observe in that pattern.

Transitions and Relative Flexibility in All of the Above


Above all else, listen for and learn to precipitate transitions in vocal
patterns, including the patterns described in the section above on mind-y
conversations. The justification for watching these things very closely is
that, when you do so, youll be prepared to see transitions in behavior.
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Here you should be concerned both with transitions to and from relatively narrow patterns. When these patterns change, something in your
clients psychological world just changedremember, this is behavioral
patterning in a context.
The thing that makes human behavior far trickier to monitor than
that of nonhuman species is that the transitions in context among nonhumans are often signaled by apparent and significant changes in the
immediately observable world. Among humans, it can be more difficult
to see what changed. A simple word can call up a rich history. An image
can precipitate a persons worst and most private fears. Very, very often
the precipitants will not be at all obvious. However, if we can see the
transition in the patterning of response, we can know where to begin
looking closelyat the cusp of those transitionsfor the relevant shifts
in context.

THE EMERGENCE OF PSYCHOLOGICAL


FLEXIBILITY
The most obvious place to see these transitions is in a traditional
exposure-based session. When I train people to do exposure-based treatment, I like to suggest that a really artful exposure session has a life cycle.
When the person is first exposed to the feared object, arousal goes up
and an inclination to avoid in various ways rises with arousal. As the
exposure session proceeds, flexibility begins to emerge. Theres a point
that we reach in an exposure session where theres a sense that weve
done our work.
When I was a boy on my grandfathers farm, my father and uncles
would cut hay in the summer. The hay would lie in the fields until it
dried in long, yellow heaps. Then a great machine would chug through
the field, gobbling up the loose hay and leaving hundreds of bales in its
wake. The farmhands would pull the tractor out with a trailer behind it,
and they would spend the day bucking bales of hay onto the back of the
trailer. At the end of the day, there would a sense of release and accomplishment. You could look out over those fields and see that stubble of
cut hay, and when you looked in the barn, it was full to the roof. There
was a sort of weariness in those moments that was a good weariness.
Some kinds of weariness leave us feeling lifeless, but other kinds of weariness leave us feeling quite alive and connected. A good exposure session
is like that. You feel tired, but its a good tired. My dear friend Philippe
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Vuille, at the end of a long, hard workshop, told me of a French expression that captures this sense beautifully: la bonne fatigue.
Watch your client when she is anxious in anticipation of an exposure session. You can see vividly the narrowing, inflexibility, and context
insensitivity in behavioral patterning that emerges when the phobic
object is presented. You will be able to observe most if not all of the
indicators described above in a session such as this. Ask your client to
speak, and youll hear her choked voice and shallow breath, the stereotypy in her speech. Youll also see how difficult it is to engage her in conversation. Her exclusive sensitivity to the exposure will be pronounced.
Emotionally, youll see little flexibility. Her facial expression will be constrained and rigid. At the end of a good session, youll begin to see the
complement to that as more flexible patterns of behavior emerge.
In a certain sense, all acceptance and defusion work is kin to exposure. All three involve events that generate narrowness and inflexibility
in responding and insensitivity to shifts in context, except shifts directly
relevant to escape. As you bring your clients into the present moment
with fused and avoided content, as you slow them down and gently
coach their kind and careful attention, youll know that those events are
losing some of their ability to control behavior as the pattern of behavior
becomes more flexible. Youll see it and hear it right before your eyes.
Listen to the voice. Youll hear a softening and increase in the flexibility of tone. The voice will take on a more rolling and fluid quality.
Youll find that it becomes easier to set the pace of the interaction. Your
client will begin to respond to your prompts to stop, notice, and then to
move on. Her ability to appreciate values connected to vulnerabilities
will begin to emerge.
In terms of physical presence, youll begin to see her shoulders drop.
Her nervous movements will begin to damp down. Her breath will
become less strained, easier, more gentle. Her bodily movements will
become more fluid.
Emotionally, watch and youll see your clients capacity to move
among different felt states increase. The end of a really solid acceptance
and defusion session will leave your client able to move between tearful
sadness and easy laughter. Its odd: if you ask a person if he can stop
and notice how frightened or sad he had been at the beginning of the
session, hell be readily able to do so. Hell somehow be in better contact
with himself as frightened, distressed, or grieving, but at the same time,
hell be more hopeful, joyful, and vital. Again, what youll see is a sort of
rolling flexibility in emotional tone.
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Flexibility in these domains is also marked by sensitivity to context.


You can see this when you make probes. For example, after a session, you
can ask about entirely unrelated values and you may find that your client
is better able to bring attention to bear in that domain and then to shift
attention back to the work done in the session.

THE DANCE BETWEEN MINDFULNESS


AND CHANGE
Most ACT protocols are laid out in a somewhat linear fashion. In the
original ACT book (Hayes et al., 1999), the treatment begins with creative hopelessness and close experiential contact with unworkablility, and
then moves on to an exploration of the control agenda as an unworkable
metastrategy. From there, it proceeds to defusing language, discovering
self, then finally to values and commitment.
Books are structured like thatthey have a beginning, middle, and
end. The pages and chapters are numbered serially. Of course, ACT can
be carried out in this general order, but this ordering has caused some to
imagine that it must be carried out in that order. Whether this is so or
not is an entirely open empirical question.
Worse still, the structure has led some to imagine that once weve
worked through avoidance and fusion, were ready move on to values and
neednt worry too much about avoidance and fusion while doing values
work. Taking this approach can be very frustrating because it often leads
to great clarity about values but little movement. Homework assignments go undone. Commitments are postponed. Other troubles that are
brought to therapy seem to crowd out the values work.
Very often this lack of movement, this stuckness, this inflexibility is
the result of the reemergence of fusion and avoidance. Theres no value
that isnt complemented by a vulnerability. One of the easiest ways to
generate fusion and avoidance is to start talking about values, especially
where a person has experienced serious losses and disconnection. Even
worse, begin talking about making commitments in those areas! Calling
to mind a value often makes immediately present how lacking we are in
that domain. For example, when a client begins valuing being a parent,
the very next thing that happens is an awareness of all the ways that he
has failed at that. At this point, we see behavior become narrow and
inflexible, and we turn back to acceptance, defusion, and mindfulness
interventions.
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But if not in the order described in an ACT book, what order? I


myself tend to be quite flexible in the ordering of the work. In principle,
the six ACT processes described in the hexaflex are not independent.
These are six lenses or facets through which we can look at a one whole
person and one whole life. On a theoretical level, I expect that we could,
in principle, start anywhere on the hexaflex. In practice, I tend to start
with a humble and gentle version of a values assessment. I like to start
with a sense of the direction clients would take in their lives if they
could.
This isnt always possible. Sometimes people come in so distressed, so
mired in suffering, so wrapped in a story of limitation, so fused, avoidant,
and inflexible that any discussion of valued directions is impossible. In
such cases, the only real way in is to settle into the room.
As I proposed in the first paragraphs of this chapter, we need to meet
our clients just where they are. If that means running a hundred miles
an hour, it falls to us to get up to speed. And having met them at a dead
run, we begin to gently engage in pace setting and bringing them gently
into the present moment.
The interventions called for in the face of very strong fusion and
avoidance are present-moment focus, acceptance, defusion, and settling
into a sense of self-as-context. As present-moment focused, mindfulness,
acceptance, and defusion interventions alter the context, behavioral
flexibility emerges and, with it, increased sensitivity to context, including that aspect of context we call consequences.
As flexibility appears, clients can be responsive to manipulations of
operant contingencies and we can turn our focus back to values, behavioral activation, and committed action. These interventions give clients
the opportunity to expand operant repertoires and pursue changes to
behavior, the appetitive consequences of which are in the behaviors
themselves.
This transition from strong antecedent aversive control to appetitive
consequential control isnt a one-way, one-time shift. Rather, behavior
will move back and forth between aversive and appetitive control. You
can respond to these shifts, shaping both as they occur in the moment.
Theres a dynamic quality to such work. When we begin to see the
telltale signs of psychological inflexibility, we slow down and move to
mindfulness and acceptance. When signs of flexibility emerge, we move
into values and committed action. Even while doing values and commitment work thats proceeding well, its worthwhile to stop for mindful
moments. In doing so, we actively shape the capacity to move with intention, on purpose, from activity to activity.
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Finally, perhaps the best place for us to look for these transitions is
in our own experience in the moment during sessions. Human behavior
is reciprocal, and when we feel our own behavior become narrow and
inflexible, its likely that the client is experiencing the same restrictions.
Even if its not the same aversive to which were responding, we dont
need to know whats generating that inflexibility in the client in order to
intervene appropriately. In the next chapter, well examine the ways that
we therapists lose contact with the preset moment and, of course, how
we can find the way back.

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Chapter 6

Therapists and the


Present Moment

The things we look for as we sit with clients are all data. A certain narrowing and inflexibility in repertoire tell us that the client has entered scary
territory. The same principles that apply to clients apply to therapists.
Bob Kohlenberg, founder of functional analytic psychotherapy, made a
great contribution to my training by teaching me that everything that
happens inside your skin in the therapy room is data too (Kohlenberg &
Tsai, 1991). And my mentor, Steve Hayes, who was at the center of my
training as a scientist, taught me that data is always your friend.

DATA IS ALWAYS YOUR FRIEND, EVEN WHEN


ITS NOT FRIENDLY
What Steve meant was that, when data dont comport with our analysis, we tend to turn away from them. But negative findings help tell us
about limiting cases. They tell us whats wrong with the study or with our
assessments, andif were very, very fortunatesometimes data can tell
us whats wrong with our theory. This can be painful news, but if were
serious about doing our jobs as clinicians and researchers right, its news
we want to get.

Mindfulness for Two

When I was learning to do therapy, a lot of things showed up inside


my skin that were decidedly unfriendly data. I had thoughts and feelings
about myself. I felt stupid and incompetent. I thought I was a fraud. I
had thoughts about the clumsiness of my interventions. Some things my
clients said hurt or terrified me, leading me to terrible self-doubt:

I have no idea what to do with this guy.


Why does she keep doing that over and over?
I dont have any idea what to do. I feel completely hopeless.
Sometimes I felt entirely uncharitable things about my clients:

This person is boring.


I really dont like this guy.
Will this hour ever end!
These thoughts and feelings were very unwelcome guests at the party.
I tried to kick them out, but they returned again and again. And while I
was busy trying to kick out those disturbing thoughts and feelings, I was
less available to my clients.
What Bob suggested, in his 1991 book Functional Analytic Psycho
therapy, was to get interested in those reactions, to take time with them,
and in particular to explore the meaning of those reactions in terms of
the relationship between therapist and client. Bob taught me to slow
down and pay attention to those reactions. He showed me that those
reactions had something to say to me, if I would just take a moment to
listen.
ACT has certainly internalized many of Bobs sensibilities, and these
are very significant to my purpose in Mindfulness for Two, since many of
these difficult experiencesreally our time spent managing themtake
us away from the present moment. We get busy and lose the only moment
we actually have. Im not talking about imagined moments, the befores
and laters. Instead I mean the very moment we inhabit with our clients
right there in that room, a moment we can either share or neglect.

PHYSICIAN, HEAL THYSELF


From my introductory comments, youve undoubtedly realized that the
focus in this chapter will be on the therapist. Well examine some of the
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same issues we looked at in chapter 5 but from the inside out. That is,
well explore how can you detect and understand disconnection from
the present moment when youre the one whos disconnected. Well look
at the most common manifestations of present-moment process failure
that youre likely to notice in yourselfwhat precipitates them, how to
identify them, and how to intervene. The process issues from the therapists side of the therapeutic interaction dont differ in kind from the
ones on the clients side. One of the radical things about ACT, and really
about behavior analysis, is that you dont need separate sets of principles
to understand client and therapist behavior. The same principles apply
to both. The best way to learn to make any discrimination is through
multiple exemplar training, which is a very technical way of saying that, if
you want to learn a basic principle, watch for it wherever it applies. Its a
mistake to use a principle to understand client behavior and then ignore
what it might be able to tell you about your own.
Its easy for us to assume that if clients are more present, theyre more
likely to profit from their exchanges with the world and the people in it.
If theyre to learn, change, and develop, we take for granted that theyll
be aided by an increased ability to focus attention on their activities. If
learning mindfulness is a priority, we practice these skills with them in
session.
If this is true for them, though, its equally true for us. By increasing
our own ability to focus on whats happening in the present moment,
we can sharpen our clinical skills. Our interaction with clients is a sort
of dance. We may lead, but we need to lead with flexibility, including
the flexibility to know when to give over the lead. We need to determine when its time to intervene and when well accomplish more by
sitting back and listening. Sometimes we need to speed things up; at
other times, slowing down is what the situation demands. In all of these
cases, studied and practiced attention to the present moment is one of
our greatest clinical resources.
Ive described the clients behavior as being in dynamic relation
with the environment. Client behavior is an evolving stream of activitya living, breathing thing. Our behavior is the same. For us, the
client is the central element in the environment of our sessions. To
fulfill our mission in the therapy roomto facilitate our clients change
and growthwe need to make close contact with them, moment by
moment. Like them, well profit the most from our exchange if were
fully present to it.

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GETTING STARTED: WATCHING YOURSELF


All of the issues discussed in the last chapter, though applied there to
clients, also pertain to you. If you have audio recordings or, better still,
video recordings of your sessions, I recommend turning your attention to
your own behaviors with the same eyes you turn toward your clients. If
you dont have access to recordings of your own work, you can practice
on some of the videos youll find on the DVD-ROM that comes with
this book. Watch for things like pitch and pace. Watch for narrowing of
behavior, insensitive persistence, posture, affective inflexibility, and all
the rest. For brevitys sake, I wont repeat the last chapter here; rather,
Ill augment it.
With clients, were limited to what we see and hear and what they
report. We dont have direct access to their great interior world. You do
have direct access to your interior world. Ironically, you have somewhat
less access to an exterior view of your own patterns of responding. This
makes listening to audio and watching video all the more valuable.
In cultivating therapeutic responsiveness to the emergence of client
inflexibility, you need to be able to see and hear the outward manifestations of inflexibility. You need to become a connoisseur of the minutiae,
the subtleties of inflexibility. To get at this from your side, though, you
need a different skill set. Watching video or listening to audio is very
instructive, but its only really instructive after the fact, or perhaps in
the present moment in a supervision or consulting group. However, in
session, your most powerful tool is careful, moment-by-moment awareness of your own interiority. This ought not be confused with the domination of that awarenessfusion with your own reactivity. Below well
deal with those things you can access that no one else can see directly.
Bear in mind as you read that what youre looking for are those moments
when you withdraw from the present moment and lose flexibility and, in
that loss, lose your client. Disconcerting though these discoveries may
be, remember that they are invaluable sources of data.

SAVANNA MIND, DANGER, AND AMBIGUITY


Recall the gift of this lovely mind that grew up on the savanna. It kept us
safe out there in a world of lions and tigers and bears. It gave us the great
gift of a relatively narrow and relatively inflexible repertoire that was
just the tool we needed to survive those harsh environs. Unfortunately,
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were capable of that narrow and inflexible repertoire even when theres
nothing hungry nearby with sharp teeth and claws.
What generates that narrow and inflexible repertoire in therapists? I
would propose that its an alarmingly high prevalence of clientophobia
among therapists. If you work with easy clients, this probably isnt an
issue for you. If your clients come in, present a few problems, seek a bit of
counsel and open discussion, then go home and get their lives on track,
you can skip this chapter. Or, if youre one of those supremely confident
therapists and have a persistently positive view of your own work, this
chapter probably doesnt apply. But if youre like me and often have a
sense of working frighteningly above your capacity, or if your clients are
like my clients, you might want to stick around.

FUSION AND AVOIDANCE IN THE FACE OF


HARD HISTORIES
There are many, many ways that clients can become aversives for therapists. The most obvious way is that they often come to us with incredible stories of pain and loss. Marriages break up. People go years without
experiencing the kind caress of another human being. Children are
abused by the people who are supposed to love and care for them. People
suffer downs that leave them in bed for weeks and anxieties that make a
trap of their homes and strangers of their loved ones.
Sometimes we dont like really difficult clients. Sometimes they
make it very hard to like them. They insult us and question our integrity:
Youre just doing your job, they say, or, You dont really care about me.
When we really like them, we experience lack of progress or relapse as
terrific pain. In an important way, the more we like the client, the more
painful his losses are.
I treated a woman years ago who had suffered the most horrific
history of childhood sexual abuse Ive ever heard. Shed been sexually
abused by both parents, and there had been a complete silence around
the abuse for nearly thirty years.
She didnt begin to disclose this history to me until a couple of months
into treatment. In fact, she denied any significant problems growing up
in response to my first probes. Treatment began with a simple question
about whether she should stay in college or return home to care for her
ailing mother. Only over time did she begin to reveal her level of selfloathing, self-injury, and suicidality. She cut and burned herself and hit
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herself on the hands and feet with a small hammer. On one occasion, she
reported to me that she had carved a word into her own thigh. Later still,
she disclosed the childhood trauma.
Over the course of three years of treatment, we came a long way
from that initial, mild, college-student presenting problem. In session,
the work was so painful at times that she would literally howl like an
injured animal. The sound could be heard all over the clinic. And, like
an injured animal, she would frequently lash out. Once, a year or so into
treatment, she was clearly angry at me. I made what was, in retrospect,
a rather ham-handed interpretation suggesting that she was treating me
as she treated her father. She responded, Oh, no. Its worse with you. I
expected it from him.
Clients like this can teach us something valuable. When we sit with
clients who are in such pain that cutting themselves provides a sort of
relief, we dont have to wonder why theyre so frequently referred, overmedicated, and hospitalized. Sitting with someone in that much pain is
painful. These clients are often abandoned by family, friends, lovers, and,
too frequently, by therapists. Its very hard not to. Its hard to sit with
pain, and its hard to sit with slow or no progress.
And when we do leave these folks, we confirm their worst fears and
most certain self-evaluation: that they are fundamentally flawed and destined to die alone and unloved. Even when we dont leave them entirely,
we leave them in smaller ways right there in the room. The pain inherent
in such clients is often compounded by wonderful intelligence, creativity, humor, and passion. Seeing that capacity unrealized makes the work
doubly hard and our own failings doubly painful. Have you failed some
of these clients? Do you know something about that sigh of relief as you
hand them off to another professional?
If theres an afterlife, I suppose that there will be special dispensations for people willing to sit with someone in that kind of pain. Marsha
Linehan, founder of dialetical behavior therapy, has my undying respect
for her devotion to work with folks with this sort of pain. I sat with
the woman I described for three years, so maybe there is some small
dispensation for me.

Noticing Process with Hard Histories


Even just reading the words noticing process with hard histories,
you may feel a bit defensive. Do you find yourself saying, Yes, but?
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Yes, but Im not running a DBT practice.


Yes, but I dont have the appropriate training for that work.
Yes, but my practice setting isnt appropriate for that level of
care.

Of course, all of these things may well be true, but if you found
yourself feeling defensive, notice that youre defending yourself again ink
marks on a piece of paper. Whats there to be argued with? Im not asking
or telling you whom you should or should not see. That wouldnt be my
place. But its worth noticing that even the mention of such clients can
sometimes move us to raise walls to protect ourselves.

Fusion with Solutions


Our more challenging clients churn up all manner of fear and selfdoubt in usat least in me. Is it just me?
This is particularly painful when at least some things they need to
do are obvious. It was very clear with the client I described above that
she needed to stop injuring herself and to keep her distance from a very
toxic family. Isnt it obvious that the chronic alcoholic client needs to stop
drinking? For the depressed person who hides in his house with the shades
drawn day after day, isnt it clear that nothing can change without him
getting up and out into the world? We dont like being so near a solution
and having it be entirely unavailable. Its all too easy to get stuck on these
solutionswhat I call solution fusion. We can keep our eyes so fixed on
those solutions that whats happening in the room can become elusive.

Fusion with ACT-Consistent Solutions


A subtler, more problematic version of solution fusion can occur
when the solution youre aiming at is ACT consistent. You see some bit
of difficult material that youre sure the client needs to accept. Some
story shes relating just screams self-as-content. Or he remains steadfastly
rooted in the past or the future, disregarding whatever it is thats actually going on right now. Sure, we subscribe to this treatment modelwe
think it does a pretty amazing job. But having the ACT seal of approval
on the side of it doesnt mean that we should seize it tightly and focus
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on it to the dereliction of everything else in the room. And it certainly


doesnt mean we need to coerce our clients into accepting it.
Consider the rape victim who needs to accept thoughts and emotions that arise in intimate contexts, or even at their mention. If we look
it into the persons life, the cost of avoidance might be very apparent. If
we look at whats happening, we may see avoidance right in the session.
When the topic is raised, the client defers the discussion to a later time,
professes incapacity, professes hopelessness, professes confusion, and so
forth. We can literally pinpoint the areas of her life where acceptance
would lead to better things. But what if shes simply not capable of being
accepting at this moment?
One of my most common errors doing ACT is to confuse what the
client needs to do with what I think the client needs to do. When Im
right, the situation is worse. When my conceptualization of the problem
is correct, Im even more likely to become fused with my solution and to
try to convince, explain, and, on my worst days, bully my client toward
acceptance. But acceptance thats forced upon a person isnt acceptance
at all. Ive just added another layer of aversive control to a client already
working in painful world.
Its worth noting the difference between being correct and being
right. We may well be correct in our analysis, but wrong in our relationship with the client and the spirit of the work. Remember, ACT
isnt about exchanging an evil tyrant for a benevolent tyrant. Its about
freeing people from tyranny.
The most frequent complaint I hear from ACT therapists is that
their clients simply will not move on stated values or that they refuse
to do acceptance work even though they know that it needs to be
done. If you find yourself in such a situation, notice your own experience
in session. Do you find yourself exhausted afterward? And here I dont
mean la bonne fatigue. This is the sort of tired that makes you rethink
your career choice. If you look into those sessions, can you find small
ways that you quit your job without even leaving the session? Even just
for a moment?

SITTING INSIDE IRRESOLUTION: THANK


YOU, MESSRS. CAMUS AND ELIOT
If you want to see how fused we can be with solutions, try the little exercise below. The exercise involves either eating or not eating a meal and
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spending some time with not knowing which. You should only try this
if youre one of the fortunate in the world who isnt one meal away from
starvation. If you want to see how minds work, heres your chance. Its a
little unfair to minds, so you have to be willing to tease your mind a bit.
But considering the way it has deviled you, turnabout seems fair play. So
far, Ive never heard of a mind dying from this, so you dont have to worry
about your minds tantrum.

EXERCISE: To Eat or Not to Eat


Prepare a meal. Sit down at the table, good and hungry. Dish up a plate.
Pour a favorite beverage. Pick up your knife and fork. Smell the food.
Move your knife and fork toward the food. And then just stoplinger a
moment. Cut a bite and pick it up with your fork. Then just stop again.
Now raise it toward your mouth and stop at the cusp right between eating
and not eating. If you find yourself not eating, gently move in tiny increments toward eating, but dont eat. Linger right there at the cusp.
Find that place right at the tipping point between eating and not
eating. Your mind wont like this. It will tell you that there is no such
thing as the place between eating and not eating. If the food isnt in your
mouth, then you arent eating! it will tell you. If its in your mouth, then you
are eating. It is that simple, it will insist. If your mind delivers this objection, please thank your mind for that observation and come back again
to that place right on the very cusp of eating and not eating. (See if you
can notice that the mind makes a pretty strenuous objection to something that doesnt exist. I mean, if it doesnt exist, what is the trouble?
Right? Goodness! Teasing minds is so much fun.)
Choose to not know whether you will eat the meal or not. Again,
your mind will object. It may even say, To hell with you! Were going to eat!
And thank your mind for that. Just sit in that place in between. Fine, we
wont eat then! Watch what shows up in your internal world:

But the food is getting cold!


Okay, how long do I need to do this?
This is stupid.
This is wasteful.
Whats the point?
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And then just sit. Let yourself go quiet. Let yourself come to your
own breath. Settle into your own body, into what it feels like to sit in
your own skin. And watch the objections rise up. Notice your own body.
Notice how intolerant you are of problems (Im hungry) and a solution so
close (a meal before you).
In the end, either eat the meal or wrap it up for later and dont eat.
Let whether you eat or not be undetermined until youre finished with
the exercise. (And notice the huge sigh of relief your mind makes when
you finally choose.) Let me further encourage you to leave the length of
time spent at that cusp undetermined. Notice all of the reactions that
well up as you wonder how long youll wait or if you will eat at all. Notice
how much you want to resolve that before the exercise is over. Notice
how insistent your mind is in the face of the undetermined. Notice how
intolerant your mind is of the unknown, even when the unknown is as
trivial as whether or not you will eat a single meal.

If you actually do this exercise, and perhaps even if you dont, notice
yourself objecting to me. Perhaps youre writing a story in your head right
now about why you dont need to actually do this. Or better still, you tell
yourself, Oh yes, very good, I will do thatlater.
Minds dont like the places in between. This is what T. S. Eliot was
speaking of as the still point. Camus likewise knew this place as
waterless deserts where thought reaches its confines. At that last
crossroad where thought hesitates, many men have arrived and
even the humblest. They then abdicated that which was most
precious to them, their life. Others, princes of the mind, abdicated likewise, but they initiated the suicide of their thought
in its purest revolt. The real effort is to stay there, rather, in so
far as it is possible, and to examine closely the odd vegetation
of those distant regions. Tenacity and acumen are privileged
spectators in this inhuman show in which absurdity, hope, and
death carry on their dialogue (1955, 910).
You can use the little exercise above to take you to a place that
minds will assert does not existthat still point between doing and not
doing. As Camus suggests, your inclinations will be to jump. Youll want
to jump in (and eat). Or youll want to jump out, to retreat (and leave the
table). Or perhaps youll find your mind wandering to other mattersan
endless stream of befores and afters.
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See if you can reflect back on the exercise and notice the relationship between that exercise and your work with clients. Isnt it often our
intolerance of the unresolved that drives us to act or retreat? And dont
we see the same in our clients? Lurching ahead on a new effort to get it
together and by turns retreating again into the house, into the bottle,
into some respite from uncertainty? Moving in either direction can function as a means to avoid uncertainty.
And, looking a bit further still, see if this uncertainty isnt present in
every truly significant value in your life. Consider getting married. How
will that turn out? Consider a career change. How will that turn out?
Consider having children. How will that turn out? And, working with
clients, how do we bind our anxiety when that world gets uncertain? Do
we know in advance how that will go?
Uncertainty lies all about us. We cant eliminate it, but we can blind
ourselves to it. But what if its the case that theres no way to blind ourselves to uncertainty that doesnt also blind us to our values? We can
hide out in certainty, and sometimes we will settle for the illusion of
control. But, in doing so, the beasts dont go away. We just cant see them
anymore. The good news is that for most of us, since leaving the savanna,
the beasts are mostly the psychological variety. Ive never been eaten in
my office, though Ive often feared it.
Camus knew this still place between action and inaction, and he
knew also its remarkable bounty. What freedom would you possess if you
could sit in the face of ambiguity and uncertainty without having to act?
If you could allow yourself to settle in and become intimate with the
odd vegetation of those distant regions? Where terror lives, there is also
bounty. We dont like these places that we dont know, but its in precisely
these foreign places that possibility lives. If there were something possible
for you in those distant regions, would you travel there with me? And
would you travel there with your clients?

THERAPIST FUSION AND AVOIDANCE


Theres reciprocity in session between therapist and client. The reason
I use an extremely difficult case to illustrate this is that the best way
to find high levels of therapist fusion and avoidance is to look for high
levels of client fusion and avoidance. If you want to find therapists who
have lost contact with the present moment and who are thoroughly
fused with some version of self-as-content, look for clients who have little
or no contact with the present moment and zero sense of themselves
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independent
of an entirely fused version of who they are and what the
world holds for them. In the last chapter we looked for signs of fusion and
avoidance in clients, and well now look for these signs in ourselves. Well
use the self-as-laboratory.
The first rule is look to your clients. If they look very, very stuck,
check yourself out. Youre likely to find a rich vein of avoidance and
fusion that can be mined. Youll not likely find this data with a smile on
your face. As I suggested, the data is always your friend, but often it does
not look the least bit friendly.
Now for a small pause for values and commitment in the face of
fusion and avoidance: Lets have a show of hands. Everyone reading, hold
up your hand if youd like to discover huge hidden hoards of fusion and
avoidance inside your own skin. Go ahead. Raise your hand. You know
you want to be rich in fusion and avoidance. No? Not so much? Why?
Well, because if we found a huge hoard of fusion and avoidance, that
would be bad. That would be a problem. And then we would have to find
a solution. And so we turn away.
And here we are, you and me and clinicians everywhere, all of us
together, having turned away a hundred times. Why are we here? Take
a moment and think about a client youve had whom you really, really
wanted to help, but whom you losta client who just never moved,
maybe one who left and you wonder about from time to time. Take a
moment and let your eyes close and let yourself see her face. Let yourself
see where she might be, right at this moment. I beg you, let your eyes
close and let yourself see your clients face. See if in that face you can see
the losses shes suffered and the seeds of losses to come. Can you, with
me, just take a moment to breathe that sadness in and out like air? Can
we, in honor of the fallen, let go of any resistance to seeing them and the
costs they paid?
I promise that Im doing so right now as I write this. I can see the
faces. The lost ones. The ones who sat across from me carrying some
small sliver of hope that I could help. And I can see their faces as they
slipped from my grasp. I can see them falling away. Can you? Will you?
Will you let those losses be your touchstone as you open yourself up to
hard material, to the unfriendly data that are nevertheless your friends?
Can we recommit to those folks right now, as if to say, I will not let your
loss be forgotten? I will keep you close as I do my work, to remind me of
why I would do such a hard thing as to look within, to remind me why I
would do such a hard thing as to sit gently in the face of ambiguity and
uncertainty.

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What Therapists Think and Feel and What They Do


To some extent, probably all clients, but certainly our more difficult
clients, precipitate hard experiences for us. They present us with impossible circumstances. Or they present us with circumstances where the
solution is painfully obvious both to them and to us, but the solution
isnt implemented. They present a nonstop stream of problems and we
can hardly catch our breath. We seem to be working productively on one
problem and the client switches to another. We have a good session and
he cancels the next two. He lashes out and fails to comply, or he complies
with such slavishness that it breaks our hearts.
All of these circumstances can occur for us as problems to be solved.
And, in a certain sense, they are. We tend to be very responsive to problems. When confronted by them, we experience a narrowing effect on
our repertoire. Sometimes our focus on problems causes us to lose the
whole, to lose what else is available in those moments. We become fused
with the problem, fused with our reactions to the problem, and fused
with our solutions. Or, if we find no solutions, we become fused with our
evaluations of that failure and try to solve the no-solution problem. All of
these layers and layers of fusion and problem solving steal these moments
from us and from the clients we serve.

How to Detect a Mind-y Conversation


The Therapist Version
Our clients have mind-y conversations with us and with themselves.
They live out their lives inside these conversations about limitation. And
so do we. We dont need clients in order to have mind-y conversations.
However, our clients will certainly precipitate mind-y conversations both
in us and with us. If we are to shift from conversations that specify the
limits of living to conversations that contain life and possibility, we first
need to be able to discriminate one from the other.
Below are variations on mind-y conversations discussed in chapter 5.
Here we focus on the particulars of mind-y conversations often precipitated by our interactions with clients. Since mindiness is mindiness, and
we walked through these from the client perspective in the last chapter,
Im going to whip through these. But do pause and reflect if anything you
read below strikes a chord with you.

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COMPARISON AND EVALUATION


Do you find yourself complaining to yourself or to colleagues about
certain clients? Do you find yourself evaluating your performance as a
therapist with some clients or perhaps changing to a different sort of client
or to a different treatment setting? Do you find that some clients occasion a lot of thought about whether you even want to be a therapist?

COMPLEXITY, BUSYNESS, AND CONFUSION


Do you find yourself confused in session, perhaps struggling to keep
the issues straight or striving to find your way as your client lurches from
problem to problem? Do you find yourself at a loss with respect to the
reason the client is even in therapy? Do you feel a sense of confusion
about what to do next? Do you feel as if there are a lot of details that you
need to keep track of?

STATEMENTS CONJOINED WITH BUT


Do you remember the section on the use of but from chapter 5?
Recall that there is a negating quality that this conjunction introduces
into the conversation. Ask yourself if a lot of your conversations with
yourself, your colleagues, or your clients include statements of the following flavor:

Id like to help this person, but


Sure, it would be great if I could listen to that kind of thing all
day, but

I know this sort of thing is hard for you, but


As is the case for our clients, when we find ourselves spouting these
kinds of but formulations, theres a better than fair chance that fusion
and avoidanceand thus a break from mindful contact with the present
momentare somewhere in the picture.

ADVERSARIAL POSTURING AND SIDE TAKING


Do you find yourself trying to convince your client of something
what she needs to accept or to do? This attempt to convince might be
overt, but it might also be quite covert as you try to nudge her toward
a place you know she needs to go. Or, by contrast, do you find yourself
certain about a sense of direction but silenced because you know your
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client wont go in that direction? What is the quality of that experience


as you sit in the room not saying what you want to say when not saying
is exhausting or demoralizing? Does your interaction have the feel of an
endless tug-of-war?

STRONG FUTURE OR PAST ORIENTATION


Do some clients cause you to persistently think about where you
went wrong with them? Do you experience a sense of hopelessness about
the futurefor them, for your work together?

STRONG PROBLEM-SOLVING ORIENTATION


Of course theres nothing inherently wrong with problem solving.
But we will want to know whether it is under reasonably flexible control
versus narrow and inflexible stimulus control. How can we know? This is
the math-problem-versus-sunset issue discussed in chapter 1. Sometimes
you can find out just by pausing and asking yourself this question: Is this
client a math problem or a sunset?

EXERCISE: Considering Your Clients


Make a list of all of your clients. Take a bit of undisturbed time and
slowly go over your list, pausing and closing your eyes a moment for each
client, allowing yourself to see this client, allowing yourself to see the
client moving around in the world he inhabits. Then ask the question: Is
this client a sunset or a math problem? You dont need to answer; in fact,
it may be better if you leave answering to one side for a moment, and just
sit with the image of the client and the question.

STRONG FOCUS ON WHAT SOMETHING MEANS


ABOUT YOU WITH RESPECT TO OTHERS
If some of your clients generate a sense of hopelessness, of helplessness, and perhaps of incompetence in you, do you find yourself reflecting
on what that means about you as a therapist, perhaps even as a person?
Do you find yourself wondering how you might stack up against your
colleagues, or how other people in your life might regard you and your
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work? Do you find yourself drifting to thoughts of how your clients might
describe you to others?
Seriously entertain the idea for a moment that youre a failure as a
therapist and that even your best efforts will fade to mediocrity. Imagine,
just for a moment, that no matter how hard you study, try, work, youll
never be able to quite get in the room with your clients. Try this thought
on for a moment: Im a really weak therapist. Sometimes I can put on a
reasonable show, but deep down, Ill never be much of a therapist. What was
your reaction to those words? Of course, I didnt ask you to accept the
fact of failure, just the thought, and even that for just a moment. At least
some of our clients will precipitate a sense of failure in us, at least some
time. How busy do you get managing that sense when it emerges?

EXPLANATION VS. DESCRIPTION


When you speak of certain clients to colleagues, do you find yourself
justifying or explaining why things are going poorly in therapy? Do you
find yourself justifying your work to yourselves or others?

CATEGORIES VS. SPECIFICS


Consider the ways that you speak and think about your most difficult
clients and about yourself in relation to them. How much of your own
speech is categorical and abstract as opposed to concrete and specific?
How much of your speech (and thought) is I cant stand this or This is
terrible? Compare this to When my client comes in and tells me about
his failing marriage, I feel helpless. I remember my own parents divorce
and how sad I felt the day my dad moved out. I see some of that sadness
in my clients eyes.

THE FAMILIAR (AKA THE OLD AND STINKY)


Winding up the mindiness list are the conversations you have with
yourself and about yourself that seem just a little bit too familiar. Do
you hear yourself saying things that youve heard before? Does the conversation you have with yourself about your competence as a therapist
have the same ring as conversations you had with yourself about being
a student, a partner in relationships, a friend? Check and see. If you sit
inside thoughts of failure for a moment, what other things from your
future and past are conjured in that stillness?

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Therapist Avoidance Strategies


Next well turn our attention to the many ways we therapists bind
the anxieties stirred up in us by our clients. Dont assume that the strategies described below are necessarily avoidant. Youll need to sort that out
for yourself. If we saw someone running down the street, we wouldnt
necessarily conclude that she was running away from something. She
might be jogging. She might be running to see a good friend up the
block who just got home. There are all sorts of reasons a person might
run. What I list below are common ways that therapists run. Some of
them look avoidant; some of them look positively virtuous. Its your job
to figure out which is which.

BEING PREPARED (REALLY PREPARED!)


Being super prepared for every appointment with clients can be a very
good way to feel safe. Of course, preparation isnt the enemy. Preparation
is fine. The difficulty arises when preparation becomes the functional
and behavioral equivalent of worry. Ive worked with therapists who
make a fetish of preparation.
When I sense some constriction around preparation, I often get
settled in for a moment with the therapist and ask him to slow down
and imagine coming into a session with absolutely no preparation at
allnot one second. If Ive read it right, hell suddenly stop breathing,
freeze like a deer in the headlights, and begin uttering a stream of but,
but, buts. I reassure him that Im not asking him to actually go into a
session unprepared. In fact, Ive not asked him to do anything except
imagine being unprepared. What fears rise up when he even considers
being unprepared? What beasts loom around the edge of those fears?
Failure? Incompetence? Worthlessness? Fears that hell get in that room
and have no idea what to say?

NOT BEING PREPARED


Although not being prepared is formally the opposite of the above, it
can be functionally identical. Some clients cause such angst that we work
hard not to think about them. Part of the way that can manifest is in a
lack of preparation where preparation is appropriate. If you find yourself
defending, with much energy or resolution, being prepared or not being
prepared, its worth examining possible fusion and avoidance connected
to preparation or a lack thereof.
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BEING BIG
Theres an old saying that the best defense is a good offense. Looking
like youre in charge can sometimes ward off feelings of incompetence,
confusion, or frustration. There are many strategies that can help you
look and feel more in charge: sitting beneath a wall of framed diplomas,
referring to authoritative studies and texts a lot during sessions, letting
your conversation with clients stray to technical topics or analyses of
analysis where you can really let loose with the vocabulary. Somehow our
profession missed out on finding a reasonable excuse for wearing white
coats and stethoscopes. But we have our ways.

BEING SMALL
Although being big in one way or another is a common method of
managing the difficulties faced as a therapist, being small can be equally
protective. There are somewhat fewer strategies available, but you may
find that these fit better with your usual methods of managing anxiety.
You might look for moments when you avoid confrontation or when you
dont say things you think your client will find painful. Watch your voice
for a flat and gentle, nonthreatening therapeutic tone. Take note if you
always find yourself being kind and nurturing, never disagreeing, or never
showing anger.

BEING AN EXPERT
Doing a lot of psychoeducation, holding forth on the theory around
treatment, and explaining the mechanics of a treatment model can be
a great way to look and feel in charge. It puts you on ground that you
certainly know with more depth than the client. On a personal note, this
is my most likely mode of protection. Im prone to going positively professorial in sessions and in supervision. The trouble is that Im often correct
in terms of content (but Im just as often wrong in process), and Ive had
some practice at sounding like I know what Im talking about. And Ive
been doing this a while, so I can go on and on and on. Sigh.

BEING CLEVER
Getting to the heart of the matter and saying it out loud can help
(well, help with feelings of incompetence). A good penetrating analytical
mind can often make sense of whats driving behavior. The trouble is,
often enough, knowing plus a dollar leaves you short of enough money for
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a cup of coffee. Knowing that going outside wont hurt a client and that
doing so will ultimately lessen his feareven if you do a very good job
of communicating this factwont necessarily alter a clients motivation
to leave the house. Being clever can take the form of insightful analyses,
interpretations, and even treatment plans. But absent a connection with
your client, your cleverest assessment or keenest insight might not do
much to move her.

ALWAYS BRINGING A CLIPBOARD


Holding a clipboard is one of my favorite ways to look like someone
in charge. Go to any construction site. Look around. Whos in charge?
Look for the person with the clipboard, not the person with the shovel.
Clipboards also have a physical presence that can serve as an actual
barrier between you and the client. Be sure to take a lot of notes during
the session. If youre really in doubt, bring a lot of scripted questions. You
will always know what to do next.

ASSIGNING LOTS OF HOMEWORK


Another good way to be on top is to spend a fair bit of time assigning
and reviewing homework. Remember school? Who gives the homework
and who gets it? The teacher knows. The student doesnt. The teacher
evaluates. The student gets evaluated. If you need to stretch it out, you
can also explain the rationale for homework in great detail.

BEING A GOOD LISTENER


Many clients are willing to fill the session with stories. Sometimes
you feel lost in this stream of stories. If you get quiet during a session, the
whole hour can go by without your having uttered but a few sentences.

CHOOSING NOT TO INTERVENE


Do you ever find yourself in session feeling like you should be doing
something? You may not know precisely what you should do, but you
have a sense that the session is going nowhere. Forced activity can sometimes manage this difficulty. Driven by your intolerance of not knowing
what to do, you might get big in the ways described earlier. But you also
might just sit and do nothing. You get busy in your head. You count the
minutes until the end of the session and breathe a small sigh of relief
when the client leaves.
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KEEPING IT LIGHT
Some clients protect themselves from hard material by coming to
session and taking about sports, politics, or other issues disconnected
from their own growth and development. Its very easy to join clients
in these conversations. The hour will fly by. A variation on this is the
client who brings in a steady stream of small problems. You can stay
busy putting bandages on small scrapes as the clients life bleeds away
from larger, more central injuries. This is a particularly palatable way of
staying small, since it has the form of doing good. And, by the way, the
same applies to clients. In moving from one small problem to the next,
they get to feel like they are doing good too.

STAYING BUSY, WORKING HARD


Some client presentations are likely to precipitate busyness. Clients
who bring in many, many problems often get us busy. Some versions of
being big also involve being busy. Watch yourself in session and see if
you tend to always put a lot of effort into your work with clients. If you
do, pause a moment in session. Allow the busyness to settle around you.
Examine your tolerance for periods of inaction. Hesitating a moment in
these pauses can tell you something about how much have to is driving
your busyness.
Another thing you might look to in this area is ongoing interest in
new therapies or a tendency to jump from model to model.

CHASING UNDERSTANDING
Another common avoidance strategy is chasing understanding.
The domination of insight-oriented psychology has a long, long reach.
Psychoanalysis doesnt have the influence it once had in mental health
training, but its residue in the form of prizing insight and understanding remains. This is unlikely to change any time soon. Its deep in the
Western tradition and also in some interpretations of Eastern traditions.
The core idea is that understanding the nature of a thing will allow us
to act more effectively in response to it. I dont believe you can overestimate the pull of understanding. Of course, understanding has delivered
extraordinary gifts.
ACT, however, isnt an insight-driven model. Its not so much that
we dont love insights. We do. Theyre lovely. But we dont believe that
insight drives behavioral and emotional change. Rather, its the other
way around. Check for yourself. Look at insights youve had. See if it isnt
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the case that the insight followed some event or activity that changed
your view.
Some years back, I was at a meeting where the leader asked everyone
in the room to stand up if they were between eighteen and twenty-two
years of age. The group leader went on to say, This is what your parents
looked like when they made those decisions youve been mad about for
the last few decades.
What did I see before me? I saw kids. I saw bright young faces, full
of promise but largely unseasoned by the vicissitudes of decades. It was
somewhat disheartening to find myself, a middle-aged man, blaming kids
for, well, acting like kids. I made a decades-delayed phone call to my dad
after that meeting. Did I have an insight? You bet. But the insight followed the experience of taking a different view.
Insight is the exhaust, not the fuel. Experience is the fuel. Insight was
also not the best thing that came from that experience. The best thing
was a renewed relationship with my dad. The experience had several
outcomes: insight, changes in relationships, and changes in my own view
of myself as a son and as a father, among others. If I could only keep one,
it would be regaining my dad.
Chasing understanding is at such high strength that ACT has a variety
of interventions aimed directly at pursuit of understanding as the royal
road to well-being. Both clients and therapists are steeped in a culture that
teaches us the virtues of understanding and insight. The trouble is that
understanding is so unbelievably useful in so many domains of living.
Understanding aerodynamics has allowed human beings to fly.
Understanding math allows people to keep their checkbooks balanced.
Understanding allowed my fine doctors to treat the cancer that threatened my life in 1998. Understanding is essential in developing a coherent
and useful theoretical account of human behavior.
Its unquestionable that some human suffering arises from deficits
in information and understanding. If someone with diabetes doesnt
understand which foods are and are not high in sugar, she may have
trouble. If someone with an alcohol problem doesnt understand that a
drinkwhether beer, wine, or whiskeyis still a drink, that person may
have trouble. But very, very frequently, people already know as much as
they need to in order to act in a way thats consistent with their values.
How many folks with diabetes know what they should and shouldnt eat
but continue to eat in ways that lead to blindness, loss of limbs, and
death? How many people with drinking problems know that they need
to stop drinking yet drink themselves out of jobs, families, and friends
and straight into graves?
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Information is powerful medicine where its powerful, and weak


medicine where its weak. Of course, our minds will always tell us that
just a bit more understanding will finally do the trick. But what if pursuing understanding isnt the best way to find it? Could this be? This is not
to discount verbal understanding. However, there are some things that
verbal understanding just cant deliver. You could read every book in the
world on swimming and still not know how to swim. To learn to swim,
you have to get in the water. The ACT model is not antiunderstanding
at all; it doesnt, however, see lack of understanding as the most important cause of human suffering. Further, ACT identifies considerable suffering in harmful overextension of verbal understanding, especially into
domains where it doesnt help.

PROVIDING CONSOLATION
One potential avoidance strategy is providing consolation to clients
who are suffering. Its quite natural to want to console someone in distress. But sometimes when clients are very troubled, we find ourselves
compelled to do so. Sometimes we cant tolerate how we feel when they
feel how they feel. In chapter 8, well use experiential exercises to explore
the strength of that compulsion.
Why would we care? Because sometimes consolation is just what the
client needs, but sometimes consolation can be insulting. When I was
being treated for cancer in 1998, I was very sick and very sad. I couldnt
look at my own children without wondering if they would have a father
next Christmas or just a story about a father. My sadness was quite apparent. I had wonderful medical care. Most of the nurses and doctors who
treated me provided a quiet presence as I sat sad in their offices. With a
few, however, it was very clear that the consolation was really more about
their feelings than mine. They couldnt sit with me, and I didnt want to
sit with them. Their words had the form of consolation, but there was
little consolation in them. Were all susceptible to this, but consider how
powerful it would be to be able to sit when sitting is called for and to
console when thats what is needed.

ALL OF THE ABOVE: MINDFULNESS


AND AVOIDANCE
None of the above phenomena are bad in and of themselves. Many are
important and valuable. Being willing to chat a bit about last nights ball
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game normalizes the conversation between a therapist and client. Being


prepared for sessions may cause clients to see that youve thought about
them and care about them. Understanding may lead to accurate and
useful case conceptualization. The question were exploring here is the
extent to which these behaviors are being organized by aversive control.
To the extent that they are, well expect to see those behaviors show the
same properties as any other behaviors under aversive control. That is,
well expect the repertoires to be relatively narrow, relatively inflexible,
and relatively insensitive to other sources of stimulus control.
The difficulty with many of these behaviors is that theyre likely to
be reinforced in several ways. Ive described ways these patterns of activity may function to reduce aversive thoughts and emotions. A second
source of reinforcement will often come from the clients themselves. For
the client whose primary patterns of avoidance are passive, a therapist
who is active and big may be quite welcome. A client who defends herself
by keeping things trivial will likely welcome a nice chat. Clients who
frantically lurch from one problem to the next may welcome a therapist
who becomes activated with each new problem.
If were in therapy and engaged in these various forms of behavior
in order to manage our own difficult thoughts and emotions, or if we
essentially join the client in his own avoidance, were less likely to be
aware of small shifts in the clients behavior. Well be less likely to be
able to intervene in a way thats sensitive to those shifts. Because of the
inflexibility in our own behavior, well likely have a much more difficult
time noticing the ways our fusion and avoidance are interacting with the
clients fusion and avoidance.

READY FOR A CURVE?


In the last two chapters, Ive described signs you can look for in your
clients that indicate a lack of contact with the present moment. And Ive
offered a rundown of similar things that you can be vigilant of in yourself. Learn to discriminate the difference between being in the room and
not, and youre well on your way to achieving mindfulness for two.
But what about the bigger picture? The subtitle of this book promises An Acceptance and Commitment Therapy Approach to Mindfulness in
Psychotherapy, and I find myself increasingly of the opinion that there are
some aspects of mainstream psychotherapys current approach to diagnosis and case conceptualization that miss the mark of much of what I
hold to be important in this work. Do you recall that I warned you to
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be on the lookout for a preference for categories over specifics in the


therapy room, as this may a sign of mindiness? Well, what about a caseconceptualization and diagnostic paradigm that is exclusively based in
categories? Syndromal case conceptualization, the dominant paradigm,
tends to favor interventions based on classification according to behavior form over moment-by-moment, functionally focused analysis. While
clinical specifics can increase function in present-moment processes,
an alternative paradigm for case conceptualization can facilitate even
greater sensitivity to these processes. Might it be that whats good for the
individual client and therapist is also good for the discipline as a whole?
Im betting that this is so. Accordingly, the next chapter sets out an
approach to experiential case conceptualization that uses the hexaflex
model as a foundation. And while it might superficially seem that this
is a deviation from my purpose of promoting mindfulness for two, I
think youll find, in the end, that it actually goes a long way toward
furthering it.

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Chapter 7

Experiential Case Conceptualization

During the past several decades, empirical clinical psychology has


focused on developing and validating treatments for various human difficulties. Since the achievement of a reasonable level of reliability in 1980
in the DSMIII, these efforts have been increasingly organized around
categories described in successive iterations of the DSM. The American
Psychological Associations Division 12, the Society for Clinical
Psychology, maintains a website listing empirically supported treatments.
The list is described as a list of psychotherapies for each disorder that
are supported by evidence from carefully-controlled studies (Society of
Clinical Psychology, n.d.).
Although the list isnt wholly restricted to DSM diagnostic categories, its largely a list of specific treatments for specific DSM diagnoses.
Likewise, the National Institute of Mental Health is largely organized
around categories that overlap substantially with DSM categories or at
least with the idea of distinct psychological syndromes such as anxiety
disorders, mood disorders, alcoholism, and so forth.
While the DSM has steadily improved in reliability, demonstrating
the validity and utility of diagnostic categories has been more elusive. In
2000, ODonohue and colleagues surveyed the authors of articles cited as
evidence for the efficacy of treatments listed in Chambless and companys 1993 report. One of the survey questions was Is a DSMIV diagnosis essential for making treatment decisions? (ODonohue, Buchanan,
& Fisher, 2000). The majority of respondents, 61 percent, said they didnt
need a DSM diagnosis to provide treatment. When experts known for

Mindfulness for Two

producing
evidence for the treatment of a diagnosis dont find treatment
utility in diagnoses, its suggestive of serious problems with the treatment
utility of the diagnostic system.

THE TREATMENT UTILITY OF DIAGNOSTICS


Consider the following recent assessment of the DSM effort:
In the more than thirty years since the introduction of the
Feigner criteria by Robins and Guze, which eventually led
to DSMIII, the goal of validating these syndromes and discovering common etiologies has remained elusive. Despite
many proposed candidates, not one laboratory marker has
been found to be specific in identifying any of the DSMdefined syndromes. Epidemiological and clinical studies have
shown extremely high rates of comorbidities among disorders, undermining the hypothesis that the syndromes represent distinct etiologies. Furthermore, epidemiological studies
have shown a high degree of short-term diagnostic instability for many disorders. With regard to treatment, lack of
specificity is the rule rather than the exception.
Concerns havebeen raised that researchers slavish
adoption of DSMIV definitions may have hindered research
in the etiology of mental disorders. Few question the value
of having a well-described, well-operationalized, and universally accepted diagnostic system to facilitate diagnostic comparisons across studies and to improve diagnostic reliability.
However, reification of DSMIV entities, to the point that they
are considered to be equivalent to diseases, is more likely to
obscure than to elucidate research findings.
All these limitations in the current diagnostic paradigm
suggest that research exclusively focused on refining the DSMdefined syndromes may never be successful in uncovering their
underlying etiologies. For that to happen, an as yet unknown
paradigm shift may need to occur
Many, if not most, conditions and symptoms represent
a somewhat arbitrarily defined pathological excess of normal
behaviors and cognitive processes. This problem has led to criticism that the system pathologizes ordinary experiences of the
human condition. (Kupfer, First, & Regier, 2002, xviii-xix, 2)
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None of the concerns regarding syndromal classification in general


and the DSM effort in particular drawn from this assessment, A Research
Agenda for the DSMV, are new. Some are, in fact, reminiscent of Thomas
Szaszs classic 1960 critique in his article The Myth of Mental Illness.
There is something new in these critiques, however: they come from
inside the establishment. While syndromal classification has always had
vocal critics outside the DSM effort, David Kupfer and company represent one of the strongest internal critiques to date.
A central problem with syndromal classification is that diagnosis is
based entirely on the form of responses. From a behavioral perspective,
this is likely to be problematic. One of the fundamental properties of the
behavior of complex organisms is its remarkable flexibility of form.
Even with a simple behavior like a lever press, a rat can be trained
to press rapidly or slowly; spaced or continuously; with its left, right, or
both paws; using only its head; or using only its hind legs. If we shape
each pattern in the presence of a particular tone, we can cause the rat to
behave differently by varying the order of the tones. The behaviors would
all look different even though theyre functionally identical. Likewise, we
can have behaviors that are functionally different but formally the same.
If we train the rat to press the lever for water when tone A is playing
and for food when tone B is playing, the presses would look the same but
would mean different things. One is an I want a drink press, and the
other is a Can I get something to eat around here? press. If we can see
formal similarity and functional difference (or vice versa) in a pattern of
behavior as simple as a lever press, does it make sense that we should be
able to categorize enormously complex behavior strictly according to its
form? We see enormous heterogeneity of response patterns even within
the most reliably diagnosed DSM categories. There are many instances
in which two individuals can have the same diagnosis and yet share only
a single symptom in common.
From a behavioral perspective, were generally more interested in
function than in form. And speaking broadly about our clinical work,
I think youd agree we all know that merely describing the form of our
clients behavior is not enough. In order to even begin to structure an
effective intervention, we need to know more than a little something
about the relation between the form of behavior and the function it
serves for our clients.
As Kupfer and his colleagues allude above, the DSM often treats
altogether continuous clusters of phenomena as though they were separate and distinct, and it categorizes individuals into discrete diagnoses,
any of which may be too broad or too limiting. Does anyone truly believe
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that there is an in-kind difference between the individual with five of


nine symptoms and the person with only four? I mean truly believe it
rather than subscribe to it in moments of legalistic or administrative
rigidity. I find it very hard to imagine.
Does this mean that biological psychiatry will never find any actual
diseases, complete with sensitive and specific biological markers, fully
elaborated pathohysiology, pathoanatomy, genetic predisposition, and
response to treatment? No. Biological psychiatry will certainly find
some. Over time, well almost certainly find some disorders that rise up
from mere syndromes to the level where they are properly identified as
diseases. It seems entirely unlikely, though, that well find a lot from
the current crop of DSM disorders, given that we dont currently have a
single major DSM Axis I disorder for which we have even a single sensitive and specific biological marker. Not even one.
Even if we find genuine causal neurological bases for psychiatric
disorders, this doesnt mean that the remedies will necessarily be biological interventions. Even where biological interventions are important,
theyre unlikely to be exhaustive in their ability to remedy the sufferers
problems. Traumatic brain injury has a clear physical cause, but much of
its treatment requires behavioral intervention. Among psychiatric disorders, we know that a significant number of individuals with psychotic
symptoms are unresponsive to our most effective antipsychotic medications. Even among those who are treated successfully, many continue to
have residual symptoms.
If syndromal diagnosis fails to meet our needs, though, it doesnt
mean for a moment that our needs are any less pressing or real. The
raison dtre for clinical psychology abides: the ubiquity of psychological
symptoms. To do the work weve all set out to do, we still need a system
for recognizing, understanding, and ameliorating these difficulties. We
need to find ways of shaping repertoires so sufferers can live vibrantly
when difficulties are present, as well as when theyre absent.
ACT is, at least in some sense, a response to this lack of resonance
between the syndromal classification of psychopathology and our observation of people and their complex struggles in the world. Instead of
looking for specific forms of certain syndromes, when we work from an
ACT perspective, we look for our clients problems in living. We start
with the notion that everyone has such problems. We also assume that
the difficulties we see in clients, while perhaps more pronounced, are not
different in kind from the sort of difficulties we all face. And finally, we
postulate that, regardless of the underlying causes, psychological suffering
is altered by the ways in which we interact with it.
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Experiential Case Conceptualization

While Ive been accused of being a wild-eyed dreamer, Im not


enough of a dreamer to imagine that the DSM framers are going to give
up on syndromal classification. Nor do I suspect that mainstream clinical
psychology will give up on it any time soon. There is, however, an alternative strategy. Its a strategy that starts small and slow. The alternative
strategy is to build out multiple alternative systems that dont require
universal acceptance in order to make scientific progress. This approach
is what were attempting to do within the ACT treatment development
community. Part of the effort is the development of a set of midlevel theoretical terms, which can themselves be analyzed in very basic behavior
analytic terms. Midlevel terms have the advantage of somewhat clearer
applicability to clinical phenomena while remaining connected to more
basic analyses. In this chapter, Ill describe such an alternate strategy for
classifying, assessing, and treating human psychological difficulties. This
diagnostic model is built around the hexaflex, with which you by now
have more than passing familiarity.

LINKING ASSESSMENT, DIAGNOSIS,


AND TREATMENT WITHIN THE
HEXAFLEX MODEL
The hexaflex emerges from a contextualistic and holistic perspective.
It treats difficulties that are continuous as continuous rather than discrete. All six dimensions of the hexaflex can be understood as continuously present from the clearest psychological problems to the problems of
everyday life. The system that follows includes very strong connections
among assessment, diagnosis, and treatment. Let us consider briefly the
continuous nature of each of the six facets of the hexaflex and in that see
how this linkage is retained.

Present-Moment Processes
Present-moment processes appear quite dimensional in nature. We
could ask at different points in the day, and from day to day, the extent
to which this is true of ourselves. We would quite likely find that we
vary on this dimension within and among days. If we examine the ways
in which such a presentation can capture clinically relevant phenomena, classic signs of anxiety and depression will be apparent in worry
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and rumination, as well as in deficits in concentration and attention.


ADHD-type distractibility might be properly probed and coded on this
dimension. Although the source of distractions might be different for a
psychotic client, the distractibility would still be sensibly coded.
Within the area of present-moment processes, we want to assess
whether the individual is able to bring deliberate, flexible, yet focused
attention to bear in the present moment. We can assess this quite simply
in several ways, by observation: Does the person perseverate on the
past or the future? Does the person make contact with her moment-bymoment experience without being directed to do so? If directed to do so,
for example, by asking her to attend to some aspect of experience in the
present moment such as bodily sensations, is she able to do so? Is she able
to then shift attention when asked to do so? Is she easily distracted? Can
the individual match the pacing of the therapist when instructed? This
latter is a present-moment processes issue because the individual cant
match pace when she isnt bringing attention to bear on the therapist.
One useful way to probe present-moment processes is to examine a
clients ability to engage in what is called in ACT self-as-processthat
is, can the client attend to and note aspects of his ongoing experience?
This can be done in an extended exercise, such as the Observer Exercise
from the original ACT book (Hayes et al., 1999). However, self-as-process can also be assessed in the context of assessment. For example, in
the context of the discussion of valued domains or of difficulties, we can
shift the conversation to questions about the clients ongoing stream of
experience, including thoughts, memories, and bodily sensations. The
clients ability to shift attention and to bring it to bear in turn on different aspects of experience constitutes a probe for present-moment processes. If extended, it constitutes a potential intervention that shapes
present-moment processes.
Note that there is a direct linkage between assessment and treatment. We assess and treat by coaching and shaping flexible, focused
attention. The only real distinction between assessment and treatment is
the duration of the probe. The purpose of the probe is to assess, probes
will probably be shorter than treatment, which aims at remediation.

Acceptance Processes
Likewise acceptance processes are wholly dimensional. We all, at
least at times, have aversions and avoid in ways that dont facilitate
valued living. We dont raise the price of our services because talking to
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Experiential Case Conceptualization

our clients or our boss about our pay makes us feel uncomfortable. We
dont ask someone for a date because were anxious about rejection. We
can assess avoided content and avoidant repertoires by asking our clients
about important valued domains, what they see as major obstacles (possible avoided content), and how they manage those difficulties when they
emerge (possible avoidant repertoires).
Assess content thats unacceptable. Remember, even things that seem
pleasant may take on aversive qualities. Intimacy may be highly valued
and terrifying. Content may take any form. Although experiential avoidance refers to aspects of ones experience that are avoided, you should
also list external events that the client avoids in assessing avoidance.
Often external events are experienced as aversive in their own right.
For example, situations involving interpersonal conflict may be avoided.
Individuals doing so may find that these situations generate anxiety, fear,
and memories of conflict that are also avoided. Remember that experiential avoidance may take many forms. What is the client rationalizing,
tolerating, ignoring, or experiencing with resignation (which sometimes
looks a bit like acceptance but without the vitality)? Where you see these
you will find avoided content. Many of the items listed here will also
be important as potential areas for defusion work. List external events,
bodily states, emotions, thoughts, memories, urges, cravings, memories
that are avoided. Finally, list the personal qualities clients see themselves
as lacking (for example, courage or intelligence).
We need to assess means of avoidance that need not appear to be
avoidant. Avoidance is defined by the extent to which a response allows
the client to avoid, escape, or attenuate the aversive content listed previously. Ask a client how she copes (for example, gets busy, distracts, or
thinks positive thoughts). What clients do when such content emerges
will provide a starting place for our list of avoidant repertoires. Remember,
the form of avoidance doesnt have to look pleasant. Depending on
a clients history, getting angry might help him to avoid feeling sad.
Conversely, getting sad may help him to avoid feeling angry. Avoidance
doesnt even always have to look like avoidance, so things like putting
up with, resignation, tolerating, fighting, and rationalizing might all be
means of avoiding.
Avoidance might also be apparent in the ways that a client relates to
others. Some individuals have learned to use others responses to them to
manage their own private experiences. For example, a clients presentation may implicitly request some particular response on your part. Notice
your own reaction to the client. Do you feel pulled to offer attention,
permission, approval, pity, condemnation, abandonment, or some other
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social exchange? Your experience of being with that client is likely representative of what it is like for others to be with her.
Psychological difficulties like anxiety and depression, for example,
dont exist in a vacuum. As we enter a conversation with a client about
taking valued directions, he will present things like anxiety and depressed
mood as obstacles. Or he will present external obstacles. However, if we
inquire a bit further about external obstacles, we often find experiential
barriers. A thankless husband might be an external obstacle, but we can
go further and assess what experiential barriers there might be to either
really saying yes to staying in the relationship or to saying no, leaving,
and seeking another relationship. Examining experiential avoidance,
both avoided content and avoidance repertoires, within a conversation
about values reminds us of problems as situated in the context of those
values. This makes it less likely that well end up problem solving for
problem solvings sake. It keeps the work contextualized in values rather
than contextualized in the usual flight from problems.
Again, both treatment and ongoing assessment exist comfortably
side by side. Level of willingness to linger in the present moment with
difficult content tells us something about client avoidance (assessment)
and is also simultaneously a sample of treatment for avoidance. The only
particular distinction is that asking a person to linger a moment might
be a brief way to collect a behavioral observation, whereas asking permission, coaching, encouraging, and shaping willingness in a more drawnout way would constitute treatment.

Defusion Processes
When we assess defusion, were interested in life-organizing stories
and in how tightly these stories organize life. Were less interested in
the veracity of the stories, although veracity will be compelling for the
therapist. Were so used to playing the true/not-true game. If a story organizes life in very constrained ways, asking about the truth of the story
is akin to asking, when we see a rat conditioned to cringe when a tone
is sounded, whether the tone is true. Sometimes de-truthifying can
be a good intervention. The bathroom is down the hall to the left, not
the right might reorganize your bathroom-seeking behavior, but most of
our clinical problems are far less likely to succumb to a simple correcting
of information. I know this is repetitious from previous chapters, but the
slope is so slippery, I want to offer extra warnings.
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Were seeking to assess the level at which stories organize life in ways
that inhibit valued livingtypically through loss of contact with other
important aspect of the current life situation. What were interested in
examining is the breadth and integration of fusion. To understand what
is assessed, it can be useful to have a sense of the continuum of fusion.
The prototype case for infinite breadth and integration would be a
case of a very strong delusion. Just for reference, a delusion is the holding
of some belief in the face of strong contrary evidence. I once treated a
fellow who claimed to have been in Vietnam and to have gone behind
enemy lines to assassinate members of the North Vietnamese general
staff and politicians supportive of the North Vietnamese Army. A look
in his records revealed that he had been in the military for a very, very
short time in 1970. Hed had a psychotic episode in basic training and
had mustered out of the military with medical discharge. When asked
about this, he replied, Do you suppose they would put assassin in my
military records? When I mentioned that his mother corroborated the
story, he responded, Yes, the government got to her too.
Of course, such delusions can be wholly impenetrable. Any countervailing evidence is simply rolled into the delusion. In fact, sometimes
strong evidence to the contrary can have a strengthening effect. Suppose
we could extract every Vietnam-era document from the Pentagon and
Department of Defense and there was no evidence for this client as assassin. I suspect the client would say, See how deep the conspiracy runs?

EXERCISE: But What of the Continuum?


Take a moment and consider the deepest and most long-standing fear
you have about yourself. If you want to see how susceptible you are to
such fears, very slowly read each of the following statements aloud and
allow the words to sink in, let yourself know the truth of it (if any) inside
your skin, inside your own life. Just notice what comes up:

Im just not very lovable. Most people dont see it, but if they
really get to know me, eventually they find out.

Im not a nice person. A lot of people dont know how petty

I can be. I talk about people behind their backs. Sometimes


I see myself doing it and I wonder, why, why am I doing this?
But there I am, being me.

Im a big mouth. I always have to have the last word. You just
cant know how many relationships this has killed. Mostly I

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dont notice until its too late. Even when I do, sometimes I
just watch myself walk off the cliff.

Im a doormat. I let everyone walk all over me. I sit in meet-

ings and other places and I have something to say, but I just
sit there like an idiot and take it. I dont know whats wrong
with me.

Im stupid. Most people think Im one of those who always


seems to get it, but Im really always one step behind. So I
pretend to get it, and then work really hard later to figure
it out.

Im guilty. Most people dont know the things Ive done, and

how much I dont deserve the things that I have. The people
who do know will never be able to look past them, no matter
what.

Im spineless. Most people probably cant tell, but I walk


around scared all the time. Ive missed out, and the people I
love have missed out so many times all because of my fear.

Im selfish. I seem to be really caring, but I never do any-

thing without expecting some kind of return. When I dont


get it, Im mad, but I never say that out loud.

If any of those had some resonance with you or called up other


thoughts that have the same flavor, notice how long those thoughts
have been hanging around. Perhaps you think that youre not really very
smart. You got through graduate school and everything, but you know
how often you were clueless in class (and kept it hidden). You know that
you had to work twice as hard to understand half as much. You know
how clear it was, sitting there among the other students, that their grasp
exceeded your own. You know that youve come up with good strategies
to keep this fact hiddensometimes even from yourself.
Just settle into that (or another scenario thats a better fit), and then
suppose that we asked someone who knows and loves you about your not
being very bright. What would they say? Might they say, What about
getting As all through grad school?
But I got a B in assessment. And, really everyone got As.
What about that student paper competition you won?
That was a fluke. I know other papers were better than mine.
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What about your job as a college professor?


There are plenty of stupid college professors.
Can you see how readily you could deflect contrary evidence? Is
there any event that has happened in your life that this loving friend
might recount for which you couldnt offer counterevidence? I assume
that we all have some version of such resilient self-deprecation. We have
often tried to argue these thoughts away, wish them away, and work
them awayand here we are. Notice your own urge toward struggle or
resignation. See if you can find any sense of life in either of those. And
further, when we reflect on the resistance these beliefs about ourselves
have to evidence, lets recall the definition of a delusion: beliefs held in
the face of strong contrary evidence.
Within the area of fusion, dimension we assess fused thoughts,
beliefs, and emotions; evaluations; stories about how the world is, what
happened (past fusion), and what the future will be like (future fusion);
why clients believe they have the problems they have (past fusion); and
beliefs about what would have to happen in order for them to move ahead
in life and whether thats viewed as possible.
Include stories about people in the clients life, especially when how
they are is a strong theme. Also include stories about past, future, and
current situations that have the feel of inflexibility. Work to get a felt sense
of the interiority of these stories (bring present-moment focus to them).
Stay out of conversations about the veracity of possibility/impossibility,
truth/falsity, or justice/injustice of the stories, except to get a felt sense of
the clients experience of possibility/impossibility, truth/falsity, or justice/
injusticestay mindful, these will hook you!
In working through the hexaflex assessment process, in your probes
for values, capacity to make contact with the present moment, and
capacity for acceptance, you will see examples of fusion emerge. The
clients inability to engage in such probes without lapsing into repetitive
stories and reasons, rumination, and worry are representative of fused
content. Intervention will differ from these probes in that in treating
well persistently draw clients back to the present moment, back to their
values, back to the possibility of accepting difficult things in the service
of their values.

Self-as-Context Processes
There are several difficulties well see in assessing self processes. The
most common difficulty will be fusion with self-as-content. Fusion with
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self-as-content is a subset of the larger process of fusion. Some fusion


is about the world, what has been, and what will be. But an important
subset of fusion is self-relevant fusion. Many of the examples provided in
the previous section are fusion with self-as-content.
The most common versions we might see clinically would be among
clients who are wholly identified with their symptoms and, at times,
with their diagnoses. Im anxious, Im bipolar, and so on. In very chronic
cases, the syndrome almost entirely eclipses the person. You may find it
difficult to have any conversation with the person that doesnt contain
substantial reference to the signs and symptoms hes experiencing.
Nonclinical examples of fusion with self-as-content include things
like fusion with certain roles. The stay-at-home mom might experience
something of an identity crisis when her children grow up and move
away. The person with a high-powered career might experience a similar
dilemma when her career comes to an end. In these instances, there is
a sense of if not this, who am I? when the role drops away or changes
substantially. Or the change in role precipitates a sense of bewilderment without any strong awareness of the source of the difficulty. Such
attachments to stories we write about ourselves are something we all
have in some measure. Many of our attachments to self-as-content likely
run under the radar, but a sense of our attachments is sometimes precipitated by crises of one sort or another. Death, near death, serious
illness, job loss, and divorce for example, can, bring attachment to role
into high relief.
The presence of self-as-contextincluding thought, emotion, role,
and bodycan be both assessed and treated by moving among different domains and examining the flexibility and context sensitivity with
which the client navigates those transitions. For example, if one asks
questions across the domains of the Valued Living Questionnaire (presented in appendix B), does the client perseverate when transitions are
prompted? Within and among domains, do we see stereotypies in speech
patterning and content emerge? If we ask the client to imagine a different
outcome for himself, given exactly the same history, can he do that with
reasonable readiness and flexibility, or does he lapse back into his story
about himself?
Another version of fusion with self-as-content can be seen among
institutionalized and some seriously mentally ill and developmentally
disabled clients. Among such individuals, we sometimes see a sense of
self that is extremely impoverished. Among institutionalized individuals,
questions to which the answer begins with the word I are often quite

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impoverished. Such individuals may be asked few questions that cause


them to be self-reflective, with the possible exception of questions about
signs, symptoms, and medications. Here there is a narrowness that is
driven by the poverty of the predominant questioning environment.
Even when clients arent institutionalized, our clinical conversations frequently become fixed on client problems. The persistence of
these narrow conversations carries the risk of actually fostering client
fusion with a narrow band of content. A conversation that moves flexibly
among difficulties and valued domains, among what is sweet and what
is sad, can provide an assessment of client fusion with self-as-content.
If done in an extended way, it can provide a treatment that promotes
flexible interaction with self-as-content and can lay the groundwork for
questions such as And who is it here that notices all that is sweet and
sad?
Likewise, doing self-as-context process work in the form of a brief
version of the Observer Exercise (Hayes et al., 1999) with a client can
both probe capacity to make contact with a sense of self that transcends
the contents of consciousness and provide a treatment that fosters such
an awareness if done in an extended form and repeated over time. All of
these are means by which we can assess our central interest in the clients
capacity to interact with self in a flexible way and to make contact with
an I that is not the content observed.

Values Processes
There are a variety of difficulties well want to assess in the area of
values. Some clients will present with a very confused sense of what they
value. As we assess using the Valued Living Questionnaire domains,
such confusion will be apparent. Other clients will present with an assertion that they dont care about anything. Ironically, they sometimes
care deeply about not caring. It is ironic, of course, because valuing not
valuing is valuing. Some clients will come to us in a state where some or
all valued domains havent been exercised in a very long time. Among
these individuals, a sense of valued direction may be weak or absent.
Another variation of client difficulties in this area will be clients
who enter treatment with different versions of strongly held values. In
one version, the value is asserted as strong and consistently lived. This
client may confess to an array of difficulties but also assert that shes an
excellent parent. What we want to assess is not so much her goodness as
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a parent as the inflexibility with which the value is held. Note your own
experience as you listen to these assertions. Does it feel as if the person is
trying to justify or defend herself? Does it feel as if shes trying to convince
you? Does it appear that shes clinging to the value like a life preserver,
or holding it gently like something treasured? Another variation on this
theme is the client who has some strong, clear value and also has a strong
sense of not living consistently with the value. Look for the presence of
either struggle or resignation with respect to the value. Sometimes what
were seeing is a sort of defensive valuing. This isnt to say that there isnt
also a deeply felt value there to be lived. However, sometimes we cling to
a value out of fear. Holding values in fear, like any other behavior under
aversive control, is likely to be less flexible and less sensitive to subtle
shifts in context. Over time, most values require flexibility to be well
lived. Assessing sources of inflexibility for potential treatment will not
strip away the value, only the driven quality of its pursuit.
A final variation worth mentioning is the client who has a very
small set of valued domains where there is much thought or activity. For
example, the highly stressed, low-paid, single parent who has narrowed
his values down to work and parentingperhaps regretfully having let
many other areas go. Narrowing of valuing is not necessarily problematic; however, when its done under duress, its worth investigating.
Ask the client to describe domains of valued living as dynamic,
ongoing patterns. Generate short narratives in relevant valued domains.
Linger inside the questions about valued domains before allowing any
answers. Stay in the questions. Again, this is not mere information
gathering. Mindful appreciation is key.
Many of the difficulties described above will arise from values fusion
either directly or indirectly. The markers for values fusion are the same
as the markers for any other form of fusion. Look for a certain narrowing
of repertoire. Look for stereotypies in patterning and content of speech
as you discuss certain values. Probes when values are absent or confused
might include questions like I get that you just dont feel like theres
anything in any of these areas for you, but if a strong sense of value were
to somehow rise up in one of these domains, which would mean the most
to you? You might ask, Was there a time when you did have a strong
sense of valuing in this area? Can you tell me about that? Was there a
time in your life when you thought this would be a lifelong value? When
was that? When did that change? What happened? Do you have any
thoughts or memories about that as we speak of it here and now?
As we do the values assessment, we need to be mindful that it is
not mere information that we seek. We want appreciation more than
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we want information. Probes in the area of values should seek specific


events that are prototypical in carrying the grit and grain of the clients
experienced value. Its hard to really get the phenomenology of a clients
value when speaking in terms of categories.
Assess for values where a sense of constraint, impossibility, have
to, or values as a burden emerges. If parenting is a value, ask the client
to close her eyes for a moment and actually see a parenting moment from
her history that exemplifies the value. If she cant recall one, ask her to
create one that would be small, simple, and sweet for her. Help her to
become mindful of that moment and ask her to help you to see and feel
what she sees and feels detail by detail. Especially early on, clients may
struggle to do so; dont push beyond their willingness. Thank them for
even showing you how hard it is. The clients difficulty in this is precisely
what we want to assess. In doing values assessment, we will see examples
of fusion and avoidance connected to values. These will in turn become
targets for treatment. As with all hexaflex assessments, extended versions
of these assessments will comprise important aspects of treatment. The
high-water mark in the area of values is the capacity for flexible, defused
valuing. Can the client become present to what he values without having
to act? To the extent that is so, he is free to construct and act on valued
patterns of behavior with sensitivity, flexibility, and a genuine sense that
those acts are freely chosen.

Commitment Processes
Work in this area begins when you assess committed action and the
meaning of commitment for clients. In a world where the client could
make and keep commitments, what commitments would she make and
keep? What is a major commitment he would like to make and keep?
What small but meaningful commitment would she like to make and
keep? Very present-moment focused assessment will be helpful here.
The major problems in the area of commitment processes include
inaction, impulsivity, and avoidant persistence. As with values processes, fusion is a central driver of commitment problems. In fact, its
almost impossible to assess values problems without seeing indicators of
commitment problems. Commitment processes are quite tightly linked
to values processes. This is true to the extent that much of the fusion
we see in assessing values is actually commitment fusion. As soon as
we speak a value out loud, the action implications of the value rise up
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psychologically.
This arising will include both what has been done and
what must be done. A history of difficulty and failure within a valued
domain is very likely to generate fusion and, with it, avoidance. Assess
client stories about commitmentespecially failures, inevitabilities,
or any story that contains a strong sense of limitation or constraint.
Youll find these if you mindfully examine commitments across valued
domains.
Assessment in this area centers primarily around inflexible stories
about commitments, both those made and those missed. Within these
conversations, well find indicators of commitment fusionstereotypy,
inflexibility, and repetition, as well as other markers of fusion and avoidance. We ask clients about commitments theyd like to make and what
they see as obstacles. We ask about what they believe they can do. We
ask about what they wish they could commit to. The target in the area
of committed action is the capacity for defused, accepting committed action. As with values, we seek for our clients the ability to make
commitments that are chosen rather than driven.

EXERCISE: Commitment Scaling


This is a good way to both assess and treat commitment processes.
Start by helping the client get in touch, as much as possible, with
some valued domain within which she would like to grow. Tell her that
youre going to ask her about commitments in some area. Make it clear
that she need not carry out any of the commitments, just generate commitments that are consistent with the direction she would like to grow.
Take a mindful moment and ask the client first to think of a major commitment that she could make in that area. Next, ask her to think of the
tiniest possible commitmentone that might not even be noticed by
someone else but which would be meaningful to her. After that, ask the
client to think of an array of commitments that might lie between those
two. Some clients will be completely unable to generate an array of commitments. Some will become very fused with some major commitment
or fused with their inability to carry out a commitment. These are all
interesting variations on fusion around commitment, especially in light
of the fact that weve explicitly told clients that they need not actually
make, let alone keep, the commitment. The probe is enough for assessment. An extended version of this exercise in treatment can serve to
build flexibility with respect to commitments.
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GENERAL THOUGHTS ON THE SYSTEM


These processes can themselves be analyzed in terms of basic behavioral
principles. Theyre at a level of abstraction thats high enough to capture
a very broad array of clinical phenomenon and yet low enough to be
directly and readily linked to a wide variety of clinical difficulties. Our
goal is the production of a fully dimensional model that can capture
any and all difficulties seen in human psychological suffering, including both clinical and nonclinical examples. The system isnt proposed as
excluding other sources of difficulties. For example, a head trauma might
have important psychological sequelae. While the head injury itself isnt
a psychological concern, the manner in which the individual contends
with that injury is.
The purposes of the system are these:
1. The system should aspire to provide a process account of
any and all forms of human psychological difficulty.
2. The processes should be at a level of abstraction such that
they have maximum scope (as described in 1) while being
at a sufficiently low level of abstraction as to be useful to
practicing clinicians and researchers alike.
3. The processes should themselves be analyzable in terms of
more basic behavioral processes.
4. The account should produce a stream of integrated basic
and applied research, as well as a stream of research bridging
basic and applied domains.
5. The account should integrate assessment, diagnosis, and
treatment such that a relatively close connection is made
among the three.
6. The account should, with training, cause the researcher or
treatment provider to see certain functional relations among
the six facets of the model as they occur in an individual
case or class of cases.
The full explication of an alternate diagnostic and its rationale is
beyond the scope of this book. However, what I will provide is a template
for doing assessment using the hexaflex as a guiding structure. The value
of such an assessment is that it creates a close link among assessment,
diagnosis, and treatment. The hexaflex diagnostic is built in the spirit
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of behavioral assessment. The earliest behavioral assessments sought to


sample the behavior of interest quite directly. If a person had a snake
phobia, we might stand him at one end of a room with a snake in a
vivarium at the other end of the room. We would ask him to walk toward
the snake as far as he was able. We would then measure the distance
between him and the snake.
Theres elegance to behavioral assessment in the direct linkage among
assessment, diagnosis, and treatment. Assessment involves proximity of
approach; diagnosis is made if the client cannot approach. Treatment
involves approach. Successful treatment is assessed by change in the
ability to approach. Similarly, we will assess each area of the hexaflex as
directly as possible and will attempt to make the same linkage between
assessment and treatment. In fact, the assessment itself forms the beginnings of treatment and informs the future direction of treatment.
Some claim that doing psychotherapy is an art. It seems clear,
when I look at my own work, that some of it has been quite artful and
some painfully artless. If we want a science of this and other therapies,
however, case conceptualization is essential. We see a continuous stream
of behavior in a client and a thousand potential contextual factors that
might be influencing that stream of behavior. How are we to understand
a behavioral episode? This is inherently a conceptual matter. We need
to be able to conceptualize troubling or fruitful episodes and recognize
the contextual determinants of that stream of behavior in order to know
what intervention might be applied to free the client to move forward in
her life.
However, theres a problem with case conceptualization. Case conceptualization quickly becomes too conceptual. Im fond of telling students that categories are lies. Categories at once mean too much and too
little. Once we get things categorized, the categorization quickly stands
in for the world. When we say that a client has a borderline diagnosis,
such a label organizes lots of behavior on the part of therapists, and often
in ways that arent very helpful to the client. In addition, its not really terribly clear what that label means, since theres tremendous heterogeneity
of signs and symptoms possible even when the label is accurately applied.
In addition, the label contains none of the heroism, beauty, intelligence,
and strength that are often also present with such clients.
ACT case conceptualizations share the danger of losing track of the
actual human being treated. Im asking you to cultivate a mindful, open,
accepting approach to clients, and Ill ask that you carry that gentle
posture forward in the development of case conceptualizations. We therapists can become quite fused with our conceptualizations to the point
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where our view of the client and his behavior is so harnessed to the conceptualization that we lose close contact with the client. Understanding
this danger, some therapists resist any sort of conceptualization. Such
a solution puts therapy entirely into the realm of art. Its not a solution
thats conducive to scientific development.
I care about science and am alive today in a dozen ways as the direct
result of the application of science. Im sympathetic to the rejection of
case conceptualization and think I appreciate the downside. But if our
science of human freedom is to move forward, we need to learn to do a
gentle dance with conceptualization. In many respects, this is consistent
with ACT as a treatment model. We dont teach our clients that thoughts
are the enemy. We teach them to hold their thoughts lightly. Thoughts
about clients arent different in kind. Thus, as therapists, we seek ways
to think about our clients, to use those conceptualizations when theyre
useful, and to gently let them go when they arent.

EXPERIENTIAL CASE CONCEPTUALIZATION


In what follows, Ill describe the Hexaflex Functional Dimensional
Experiential Interview (HFDEI). This is an unusual interview. First, it
doesnt bow to syndromal classification. The user of the interview need
not discard syndromal classification. Many circumstances require them.
Although the diagnoses in the HFDEI are not DSM syndromes, many
of the signs and symptoms required for DSM diagnoses will be elicited
in the context of this interview. Second, the interview is organized
around a dimensional understanding of psychological difficulties. Third,
and probably most unusual, the interview contains significant experiential components. The interview for the hexaflex is not a mere series
of questions; rather, it involves a set of questions embedded in a series
of experiential exercises. The exercises and questions will provide you
with directly observable samples of client behavior that will allow for
rating those behavior samples in terms of the six facets of the hexaflex.
The entire interview is embedded in a series of questions about valued
domains of living.
ACT is not a treatment aimed at the elimination of symptoms; its a
treatment aimed at the enhancement and development of valued living.
Because theres an intimacy between values and vulnerabilities, an examination of values is a likely entry point to seeing the relationship between
difficulties with behavior change processes on the one hand and mindfulness processes on the other. In addition, such an interview helps you and
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your client remain closely connected to the ACT model. Work with client
struggles is always directed and dignified by valued living. Likewise, progress in ACT is ultimately to be found in increases in valued living.
This interview is in its earliest developmental stages. Because of this,
I recommend that you use it in conjunction with all usual and valuable
assessments that constitute good ethical treatment. The interview does
not, for example, contain a formal mental status examination, although
in my experience its quite simple to assess all aspects of mental status
within the interview. I currently recommend using the interview in conjunction with a good symptom checklist. The interview can be quite
compelling, and I dont want you to neglect screening questions for things
such as suicidality, homicidality, and substance abuse, for example. In
addition, many will use the DSM in treatment environments where syndromal classification is a requirement. I anticipate that many, if not all,
of the data needed for a DSM diagnosis will emerge within the interview
process. Any additional gathering of information should be guided by the
practitioners ethical responsibility to provide sound treatment.

Hexaflex Functional Dimensional Experiential


Interview (HFDEI)
The following interview consists of six components. Taken together, they
comprise a set of interventions and assessments that could be used as the
initiation of treatment. Several of the components are also usable in a
stand-alone form. Ill describe them in the sequence intended for the full
interview and will also suggest ways interview components might be used
alone. The interview consists of the following six steps:
1. The therapist introduces the HFDEI.
2. The client completes the Valued Living Questionnaire.
3. The therapist does the Sitting Inside Significant Questions
Exercise with the client.
4. The client completes Experiential Writing Exercise.
5. The therapist and client complete the experiential interview
using hexaflex rating scales and worksheets.
6. The therapist completes a working hexaflex case formulation.

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INTRODUCING THE HFDEI


Most diagnostic interviews involve the systematic enumeration of various
signs and symptoms that would allow a diagnosis. In order to orient the
client to the hexaflex diagnostic, you simply introduce the diagnostic by
saying something like the following:
Im deeply concerned for the ways that youve suffered. Many treatments
examine the nature of that suffering quite directly. My approach will differ in
that Im most interested in the ways that your suffering has obstructed the sort
of living youd like to do. Perhaps its stopped you completely in some areas. It
may also be that youve continued to do well in these areas, but your suffering
has taken some of the vitality and joy out of areas of living that are important
to you.
Well start by taking a very close look at areas of living that many people
value, and well look for the ways that youve felt restricted or perhaps just
ways that youd like to grow and develop. In the midst of this, well find your
major difficulties, but well see them in light of what you value. Some of the
conversation well have will involve me asking you to close your eyes, relax,
listen, and perhaps visualize some domains of living that are of differing importance to you. Well take our time in order to cultivate an appreciation of what
youve suffered and how that fits in your life.

USING THE VALUED LIVING


QUESTIONNAIRE-2
This interview uses a slightly extended version of the Valued Living
Questionnaire (VLQ-2), which appears below. This version contains the
original VLQ items (see appendix B) in a slightly altered form, along
with additional values-oriented questions. It asks the client to look at
life domains and to answer a variety of questions. Clients are asked to
assign a numerical rating from 1 to 10 stating the extent to which they
(1) think it possible that something meaningful could happen in their
life the domain, (2) find the domain important to their life at this time,
(3) find the domain important to their life as a whole, (4) have acted in
the service of a value within the domain in the past week, (5) are satisfied with their level of action in the domain in the past week, and (6)
are concerned they wont make as much progress in the domain as they
would like.

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On a separate page of the VLQ-2 (which appears only in the PDF


version on the accompanying disc), clients are asked if they had to choose
only five areas that they could work on, which would they choose; if they
could only choose three, which would they choose; and if they could
choose only one, which would they choose. They are asked to consider
these questions both at this time in their lives and in their lives as a
whole. The version of the VLQ-2 below is for your ease of reference. If
you plan to use the VLQ-2 with clients, please use the copies of the PDF
version on the accompanying disc.

Valued Living Questionnaire


Below are areas of life that are valued by some people. We are concerned with
your quality of life in each of these areas. Youll rate several aspects in regard
to each area. Ask yourself the following questions when you make ratings in
each area. Not everyone will value all of these areas, or value all areas the
same. Rate each area according to your own personal view of each area.
Possibility: How possible is it that something very meaningful could happen
in this area of your life? Rate how possible you think it is on a scale of 1 to 10.
1 means that it isnt at all possible at all and 10 means that it is very possible.
Current importance: How important is this area at this time in your life?
Rate the importance on a scale of 1 to 10. 1 means the area isnt at all important and 10 means that the area is very important.
Overall importance: How important is this area in your life as a whole? Rate
the importance on a scale of 1 to 10. 1 means that the area isnt at all important and 10 means that the area is very important.
Action: How much have you acted in the service of this area during the past
week? Rate your level of action on a scale of 1 to 10. 1 means you havent
been active at all with this value and 10 means youve been very active with
this value.
Satisfied with level of action: How satisfied are you with your level of action
in this area during the past week? Rate your satisfaction with your level of
action on a scale of 1 to 10. 1 means you arent at all satisfied and 10 means
youre completely satisfied with your level of action in this area.
Concern: How concerned are you that this area wont progress as you want?
Rate your level of concern on a scale of 1 to 10. 1 means that you arent at all
concerned and 10 means that youre very concerned.
170

Possibility

Current
Overall
Importance Importance

Action

Satisfied
with Action

Concern

1. Family (other than marriage


or parenting)
2. Marriage, Couples, or Intimate relations
3. Parenting
4. Friends and Social Life
5. Work
6. Education and Training

8. Spirituality
9. Community Life
10. Physical Self-Care
(diet, exercise, and sleep)
11. The Environment (caring for the planet)

171

12. Aesthetics
(art, literature. music, beauty)

Experiential Case Conceptualization

7. Recreation and Fun

Mindfulness for Two

SITTING INSIDE SIGNIFICANT


QUESTIONS EXERCISE
Introduce and present justification for the exercise Sitting Inside
Significant Questions, which is a values-focused centering exercise,
saying something like the following:
In this first part, were working to get a sense of how different life domains
are more or less important to you. Weve both come in here kind of busy,
with the activities from the weeks, days, hours, and minutes before pushing us
along, and I want to make sure that we treat these topics with the respect and
attention that they deserve. So Id like to take just a minute briefly for us to
settle here in the room and to call to mind these different domains. First, Ill
help you to settle in, and then Ill ask you a series of questions. When I begin
to ask questions, you dont need to come up with answers. Instead Ill ask you
to just linger with the questions. Ill pause with you, and together well just see
how each group of questions moves us.
Say the following slowly, using a soft, deliberate voice. Pause frequently and allow yourself and the client to settle into the questions.
As you move through each set of questions, note any shifts in physical
indicators of psychological flexibility. Watch especially when you transition from one domain of valued living to the next. Watch for changes
in breath, in nervous movements, and other transitions. The HFDEI
worksheets contain places to rate and make qualitative notes about any
physical changes you notice. Each of the domains of valued living will
be explored in detail in the interview, so, though you might be drawn
to inquire around changes youll see, please use this first exercise with a
relatively passive observation and appreciation.
First, let your eyes close and see if you can just breathe in the experience
of being here in this room right now. See if you can allow your eyes to gently
close. Sit up straight in your chair with your head balanced at the top of your
spine, allowing your shoulders to drop and the muscles in your face to relax.
I want you to just take a moment, and I want you to just let your attention
come gently to rest right now on the inflow and outflow of breath. And if you
find yourself thinking forward to what were doing, gently let go of that and
notice again that in the midst of all that mental activity, your breath continues. No matter how busy you get, its there, flowing like a river. It requires
nothing of you. Just let yourself linger for a moment inside that steady stream
of inflow and outflow of breath. Each time you find yourself drifting away
in thought, into the future or past, just let that steady inflow and outflow
draw your attention gently back. Allow yourself to just notice all of the tiny
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Experiential Case Conceptualization

sensationsin your lips, your mouth, the gentle rise and fall of your own
breatheach time you drift, gently returning back to your own breath.
And if you find yourself irritated, wanting to move along, just notice
thatthat pushand imagine that you just gently release that and come
back to this very next breathand this breath.
You should ask the client to keep eyes closed and transition directly
into the following:
Im going to ask a series of questions about areas of life that some people
value. Some of these areas may be very important to you. Others may not.
Some areas you may think, no way! Others will seem just right. Its not necessary that you value all areas. I just want you to listen to the questions and
allow yourself to sit for a moment with each set of questions. Even if the area
isnt one thats important to you, just let yourself be curious about the question. Notice any thoughts, feelings, sensations, or memories that come up for
you and then gently release them. These are important areas of living, and we
dont always pause and give ourselves time to appreciate them. I dont want
you to necessarily answer these questions. Just imagine that these questions
flow over you like water. Just let the questions soak in. If you find yourself
drawing any conclusions, just gently let go of those conclusions and return to
the question.
And as you notice your reactions, let go of the urge to understand them,
to judge them, to grip onto them, or to push them away. When you notice your
reactions, just breathe that experience in, and on the next exhale, slowly set it
aside and see what shows up next.

Family
Lets look at the area of family generallyoutside of marriage and parenting. Ask yourself, if something were to happen in your life in the area of
family, what would that mean to you? What does it mean for you to be a son/
daughter, a brother/sister? What does family mean to you? Listen to these
words and just let yourself settle into each of them, noticing whatever shows
up. [Allow pauses between each word.] Brother, sister, grandmother, grandfather, granddaughter, grandson, cousin, aunt, uncle, niece, nephew, family.
Once again, just allow yourself to settle into those questions. Let yourself settle
into the meaning of these things for you and allow your awareness to stretch
out into the questions.
And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]
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Mindfulness for Two

Marriage, Couples, or Intimate Relations


And now well begin with intimate relations. Please allow yourself to sit
within these questions. Ask yourself, if something were to happen in your life
in the area of intimacy, what would that mean to you? What does it mean for
you to be a lover, a partner, a husband/wife? Just allow yourself to settle into
those questions, allowing your awareness to stretch out into the questions.
And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]

Parenting
Ask yourself, if something were to happen in your life in the area of parenting, [if the client is not currently a parent, say, even if you arent a
parent now, let yourself stretch out in imagination,] what would that
mean to you? What does [or would] it mean for you to be a parent? Once
again, just allow yourself to settle into those questions, allowing your awareness to stretch out into the questions.
And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]

Friends and Social Life


Next, lets look at the area of friendship. Ask yourself, if something were
to happen in your life in the area of friendship, what would that mean to you?
What does it mean for you to be a friend? To have friends? If your friendships
grew and changed, what shape might they take? Would old friendships be
renewed, would new friendships grow? Once again, just allow yourself to settle
into those questions. Once again, let yourself settle into the meaning of these
things for you and allow your awareness to stretch out into the questions.
And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]

Work
Next, lets look at the area of work. Ask yourself, if something were to
happen in your life in the area of work, what would that mean to you? Would
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Experiential Case Conceptualization

it perhaps mean finding new life in the work you do? Or perhaps is there is
other work youve wanted but held back from moving toward? Whatever it
means, just allow yourself to settle into this question. If something new, something with life could emerge in work for you, what would that mean to you?
Once again, just allow yourself to settle into those questions. Once again, let
yourself settle into the meaning of these things for you and allow your awareness to stretch out into the questions.
And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]

Education and Training


Next, lets look at the area of education. Ask yourself, if something were
to happen in your life in the area of education, of learning something new, or
learning more in some area that you care about, what would that mean to
you? Would it perhaps mean finding new life in learning? Is there perhaps education youve wanted but held back from moving toward? Whatever it means,
just allow yourself to settle into the meaning of these things for you and allow
your awareness to stretch out into the questions.
And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]

Recreation and Fun


Next, lets look at the area of recreation. Perhaps youve let go of some
things in the area of recreation or you might want to start something new.
Take a moment and see yourself at play. Ask yourself, if something new were
to happen in your life in the area of recreation, play, or relaxation, what would
that mean to you? Try this thought on: Im a person at play. Listen to these
words and just let yourself try each on for a moment: entertainment, sport,
vacation, hobby, holiday, leisure, fun, rest. Whatever they mean to you, just
allow yourself to settle into the meaning of these things for you and allow your
awareness to stretch out into the questions.
And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]

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Mindfulness for Two

Spirituality
Next, lets look at the area of spirituality. Ask yourself, what is the place of
spirituality in your life? Take a moment and see yourself in your spiritual life.
If something new were to happen in your spiritual life, what would that mean
to you? Try this thought: Im a spiritual person. Listen to these words and just
let yourself try each on for a moment: spirituality, sacred, reverence, ritual,
religion, faith, holy. Whatever they mean to you, just allow yourself to settle
into the meaning of these things for you and allow your awareness to stretch
out into the questions.
And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]

Community Life
Next, lets look at the area of community. Community can mean many
thingsyour country, your town, your neighborhood, your church community, a club you belong to. And it can mean many activitiesvolunteer,
neighbor, club member. Ask yourself, what is the place of community in your
life? Who are you in the communities you inhabit? Who would you like to
be or become? Take a moment and see yourself in your community life. Ask,
if something new were to happen in your community life, what would that
mean to you? Whatever it means to you, just allow yourself to settle into the
meaning of these things for you and allow your awareness to stretch out into
the questions.
And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]

Physical Self-Care
Next, lets look at the area of health and self-care. No matter your current
state of health, let yourself imagine developing and growing in this area. What
would it mean to truly care for yourself? Take a moment and try on this
thought: Im a person who takes care of myself. If something new were to
happen in the ways you care for yourself, what would that mean to you?
What would that look like? Listen to these words: healthy, fit, strong, well,
vigorous. Whatever they mean to you, just allow yourself to settle into the
meaning of these things for you and allow your awareness to stretch out into
the questions.
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Experiential Case Conceptualization

And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]

The Environment
Next, lets look at the area of the environment. Ask yourself, what role does
being a good steward of the environment and of the planet play in your life?
What would it be like for you to work for cleaner air and water, a reduction of
greenhouse gasses, and more conscientious use of our natural resources? See
yourself as a caretaker of the global community. If something could happen
in your life that would make it possible for you to care for the planet, what
would that be?
And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]

Aesthetics
Finally, lets look at the areas of art, music, and beauty. Maybe you dont
enjoy the arts as often or as deeply as you would like. If you could be a
part of creating beauty in the world, what could that mean for you? Maybe
you would attend more concerts or spend time learning or playing a musical
instrument. If you love literature, maybe you would spend time each week
with a great bookor start writing one yourself. Let your awareness flow
into these possibilities.
And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]
Let your awareness touch gently each of these areasfamily, intimate
relations, parenting, friendship, work, education, recreation, spirituality, community, and self-care. And now Id like to call your attention gently back to
your own body here in this room right now. In just a minute, Im going to ask
you to open your eyes and take ten minutes to write about what shows up for
you as the most important thing or things in your life, and why this is important and meaningful to you. Write your deepest thoughts and feelings about
this area of living. What you write doesnt have to be grammatically correct.
Dont worry about spelling or even necessarily writing in complete sentences.
Please write for the entire ten minutes. If you cant think of what else you
might say, just write the last thing you wrote over and over until something
new comes up. When youre ready, open your eyes and begin writing.
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Mindfulness for Two

EXPERIENTIAL WRITING EXERCISE


Give clients ten minutes in the room alone to write about their values.
Give the following written instructions:
Please write about some of the domains that weve just touched upon and
what they mean to you. In your writing, I want you to really let go and explore
your very deepest emotions and thoughts. As you write, try to allow yourself
to experience your thoughts and feelings as completely as youre able. This
work is based on evidence that pushing disturbing thoughts away can actually
make them worse, so try to really let yourself go. If you wish, no one will look
at what you write. Although I would prefer it if you leave it here for me to put
in your file, you may take it with you after the session. After you write, well
talk about what the writing and the exercise brought up.

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Experiential Case Conceptualization

Experiential Interview Using HFDEI


Worksheets and Rating Scales
Complete the experiential interview using the HFDEI worksheets and
the HFDEI rating scales. Before describing the interview process below,
Ill introduce the worksheets and rating scales.

HFDEI WORKSHEETS
The HFDEI worksheets are a graphical view of the hexaflex model with
areas to make notes in each facet of the hexaflex. I currently use the
hexaflex for session observation (both live and recorded), for writing case
notes, and, finally, for use in this interview. (Below, and in PDF format
on the disc that comes with this book, Ive included one worksheet that
was used to code the first seven minutes of the video segment Emily
and Kate: Session 2. On the disc, look for the file titled Emily and Kate
2 HFDEI.pdf). Well use these worksheets in the hexaflex diagnostic
interview. Theres no difference in application between coding a segment
of a session, a whole session, or an intake interview, except that ratings of
whole sessions will be more global than you could reasonably make based
on a few minutes of a session.
The worksheet also contains a place to make numerical ratings for
each dimension of the hexaflex. In the examples later in the chapter, I
provide a description of observed behaviors in each dimension of the
hexaflex and a rating of client functioning in each dimension. The
ratings go from 1 to 5, where 1 is given for minimal functioning and 5 is
given for optimal functioning. Youll find both the longer narrative and
a brief version of the anchors for these rating scales. Look at the rating
scales, look at the video segment, look at the sample hexaflex worksheet,
and, finally, look at the case conceptualization below for the worksheet
example. Ive included additional coded hexaflex worksheets and case
conceptualizations on the DVD-ROM that accompanies the book; those
examples analyze each of the six experiential role play segments.

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Mindfulness for Two

CASE CONCEPTUALIZATION OF
WORKSHEET EXAMPLE
Look at the hexaflex worksheet and watch about the first seven minutes
of the video segment Emily and Kate: Session 2. Youll see on the worksheet that the therapist has handwritten some reminders that would contribute to ratings on the different facets of the hexaflex. The client in
the video, Kate, is a thirty-three-year-old woman who is the mother of a
small child. Shes a nontraditional college student and reports recurring
problems with depression and anxiety. In the current session, the primary
concern Kate has revolves around a recent experience in a biology class.
She had misspoken in answering a question and felt humiliated in front
of her classmates.
Im not advancing the following observations with certitude. Like
any case conceptualization, this is a work in progress. Some of the hexa
flex coding that follows, I think, amounts to reasonably sound conclusions. Some of it strays into hypothesis or hunches that I think are well
worth probing. Above all, the coding strategy Ive employed is focused
on developing good clinical questions. Good clinical questions make for
good clinical answers.

Coding Present-Moment Processes


In coding present-moment processes, several features emerge as
likely markers of failure of those processes. Most obvious is Kates level of
rumination. Shes deep in a story about how things went in class and how
she shouldnt have tried to answer. Its apparent in her presentation that
this past mistake dominates her awareness. Even when Emily, the therapist, attempts to make aspects of that memory present by directing Kates
attention to different details, Kate responds in terms of categories instead
of specifics. Kates engagement with Emily is thereby diminished.
Even when Emily probes, by expressing genuine concern for Kate
and by prompting eye contact, Kate is largely uninfluenced by these
probes and remains connected to the miserable past event. What is
before her, in this moment, is a conversation with someone expressing
care and concern. She makes only glancing contact with Emily and with
that concern. I see a slight transition, however, toward the end of this
segment, when Kate begins describing her experience as its occurring in
the moment.
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Experiential Case Conceptualization

In rating this segment for present-moment processes, Id probably


give it a 1, with Kates level of contact rising to perhaps a 3 toward the
end of the segment. If you listen closely, youll hear some softening, an
opening to the present moment, though tentative and likely fragile,
toward the end of the segment.

Coding Experiential Acceptance Processes


In coding experiential acceptance, several behaviors stand out as
serving to protect Kate from difficult experiences. Most apparent is her
interaction with Emily that I mentioned above, which in the session Kate
herself calls having her guard up. For example, Kates eye contact with
Emily is limited to quick, challenging glances, and she interrupts Emily
several times to demand explanations for the work theyve done. Even
when Kate is silent, it seems a panicked or at least busy silence, in which
shes planning her defense or offense. Opening up to seeing Emilys apparent concern for her would likely make her own concern more present,
something that she has decided she cant have. This guardedness doesnt
seem to be totally impermeable, however, as Kate responds to Emilys
request for eye contact by lingering just a moment before returning to
her story.
Id rate the segment as a 2 for acceptance processes. Kate is highly
avoidant; though, as with present-moment processes, shes capable with
considerable prompting of letting down her guard just a bit.

Coding Cognitive Defusion Processes


Several examples of fusion seem to hover in the room throughout
this segment. For one, Kate holds tight to the idea that she cant let her
guard downan idea that she felt was confirmed when letting her guard
down in biology class resulted in humiliation. Related is the idea that she
cant look stupid. At the heart of both of these ideas seems to be some
fusion with the idea that she may, in fact, be stupid. Kate appears certain
that if people really saw her, this is what theyd see. Fusion is also evident
in her demands of Emily for justification for the work from their previous
sessions that encouraged her to ask the question that got her humiliated.
She appears to be fused with the idea that there may not be a reason that
justifies her work in therapy because she may not actually be able to be
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Mindfulness for Two

helped. Other fused ideas include these: Im hopeless. It is hopeless.


I was stupid to even try.
Id rate defusion processes in this segment as a 1. Kate appears quite
rigidly fused with her evaluation of her situation and its prospects. Theres
little evidence in this brief segment of any softening in the ways those
thoughts are organizing her behavior.

Coding Self Processes


In the segment, I see interplay between Kates avoidance and her
fused self-conceptualizations. She guards herself from Emily, which suggests that she sees herself as someone who needs to be guarded. She acts
to avoid looking stupid, which suggests that she may see herself as stupid.
She describes learning to hide from others and to be silent, which suggests that she may see herself as one who should be hidden and one who
has nothing to say.
In rating self processes for this segment, Id give a rating of 1. Kate
shows no evidence of a sense of her self that goes beyond her current
sense of self-as-failure.

Coding Values Processes


Kate seems to value at least one domain in this segment: education.
If you take a look at Emily and Kate: Session 1 on the DVD-ROM, youll
see earlier evidence that this is a valued domain for her. Education is
precious to Kate in part because she sees getting an education as part
of being the parent that she would choose to be. In the presence of this
humiliation and harsh self-criticism, however, Kate exhibits little, if any,
connection with either her education value or her parenting value.
Id rate values processes as a 1 for this segment, possibly rising as
high as a 2 when Kate begins to open up toward the end of the session.
Note how avoidance and fusion leave values virtually invisible. As suggested in earlier chapters, though, its worth noting the intimacy between
what Kate values and her vulnerabilities. An additional value of Kates
that I might hypothesize is in the domain of social relations. A potentially fruitful line of inquiry with Kate might be the value and meaning
of being seen, appreciated, and included in her learning community. I
would wonder what it would mean to her to truly be a member of that
community.
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Experiential Case Conceptualization

Coding Committed Action Processes


When Im coding committed action, Im interested not merely in the
times that a client has successfully committed to engagement in valued
living, but also in the ways that the client responds to times that arent so
successful. This distinction comes out in this session a couple of times.
First, Kate has returned to therapy for another session. She undoubtedly
knows what difficult things to expect from Emily and from the session,
and she shows up anyway. In addition, her avoidance and fusion arent
entirely consistent, even in this brief segment. Kate becomes increasingly
responsive to Emilys direction to contact her experience more fully. This
suggests that Kate may soon notice the inconsistency between remaining
fully guarded and her values, and then turn gently back toward living her
values.
Id rank this segment as a 2 for commitment. Although theres considerable fusion and avoidance around making and keeping commitments, she did show up for the session. This amounts to commitment
with ones feet. Questions about this domain might include these:

What might commitment look like for someone with your


doubts and with this hard week ringing in your experience?

What would a tiny committed act look like?


Is being here today part of that commitment?
Kates response to these questions might provide part of the treatment for her fusion, as she generates even small samples of commitment.
After all, generating a commitment is part of commitment.

HEXAFLEX ANCHORS

Present-Moment Process Narrative Anchors


A SCORE OF 5
The client exhibits connection with his experience in the present
moment both when speaking and when listening to another. The pace,
rhythm, intonation, volume, and content of the clients speech are fluid
and flexible. Pace rhythm, intonation, volume, and content are readily
prompted. The clients posture, facial expression, eye contact, and
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Mindfulness for Two

gestures
facilitate connection with what the current contents express,
on the part of both the client and the listener. Even when the content
is focused on the past or on the future, the client is connected with
its moment-to-moment expression. Speech content is frequently specific and detailed. The client readily provides specifics and details when
prompted, and speech that is uniformly categorical is uncommon. The
client gently shifts attention between aspects of his experience, maintaining or quickly regaining his connection with his experience. The
client is able to identify when hes not connected to his experience in
the present moment, and to precipitate that connection independently.
The client reliably reconnects with his experience in the present moment
when directly prompted. Worry and rumination are rare.

A SCORE OF 3
The client exhibits inconsistent connection with her experience in
the present moment, perhaps having difficulty only when listening or
only when speaking. The pace, rhythm, intonation, volume, or content
of the clients speech may sometimes shift into stereotypy. Instructing
change from stereotypies is possible, but shifts back to sterotypies are
common. The clients posture, facial expression, eye contact, or gestures
sometimes prevent connection with the listener. The client sometimes
has difficulty staying connected in the present moment with expression of content, especially when content is focused on the past or the
future. Speech is frequently categorical and lacking in specific and
detailed content. The client responds to directions to provide specifics
and details, but her speech frequently shifts back to categorical mode.
The client sometimes perseverates on particular aspects of her experience and may sometimes shift attention abruptly, losing connection with
her experience. The client usually reconnects with her experience in the
present moment when directly prompted but rarely notices when shes
not connected. The client is unlikely to reconnect without prompting.
Worry and rumination are somewhat common.

A SCORE OF 1
The client exhibits almost no connection with his experience in
the present moment, either when listening or when speaking. The clients speech almost always takes on marked stereotypy with respect
to pace, rhythm, intonation, volume, or content. The clients posture,
facial expression, eye contact, and gestures almost always prevent connection with the listener. The client almost always has difficulty staying
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Experiential Case Conceptualization

connected
with expression of content that is focused on the past or the
future. Speech is almost always categorical and lacking in specific and
detailed content. Response to directions to provide specifics and details
are short-lived, and his speech almost always shifts back to categorical
mode. The client almost always perseverates on particular aspects of his
experience, and shifts are almost always abrupt. The client rarely reconnects with his experience in the present moment when directly prompted,
and may actually become more disconnected. Worry and rumination are
common.

Present-Moment Process Abbreviated Anchors

12345
Speech stereotyped and
insensitive to instruction
for pace and content

Speech fluid and


5 sensitive to instruction
for pace and content

Physical presentation takes


1
away from connection

Physical presentation
adds to connection

Worry and rumination


common

Worry and rumination


rare

Perseverates and shifts


abruptly

Shifts attention easily


and gently

Categorical speech
common, details difficult
to elicit

Categorical speech
5 uncommon, details
readily elicited

Doesnt notice when not


present

Notices when not


present

No change or less present


1
with direction

More present with


direction

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Mindfulness for Two

Self Process Narrative Anchors


A SCORE OF 5
The client describes and experiences herself in a variety of ways
without being attached to any particular diagnosis, symptom, thought,
emotion, positive or negative self-evaluation, social role, personality trait,
physical characteristic, or other conceptualization, independent of its
veracity or falsity. The client transitions easily and appropriately from
one content area to the next as the situation demands. This flexibility among self-conceptualizations fosters contact with an experience of
herself apart from those conceptualizations. The client is able to contain
and readily connect with any aspect of experience even when content is
difficult. She can readily take different perspectives when prompted and
may take different perspectives spontaneously.

A SCORE OF 3
The client describes and experiences himself in a variety of ways
but frequently becomes attached to particular diagnoses, symptoms,
thoughts, emotions, positive or negative self-evaluations, social roles,
personality traits, physical characteristics, or other conceptualizations,
especially when content is difficult. The client sometimes has difficulty
transitioning among content areas as the situation demands, even when
prompted, and may act ineffectively in certain situations as a result. The
client rarely contacts a sense of himself apart from self-conceptualizations.
The client sometimes allows conceptualizations of himself to limit activities. He can take different perspectives with difficulty when prompted
and rarely takes different perspectives spontaneously.

A SCORE OF 1
The client describes and experiences herself in very limited ways,
and repeatedly becomes attached to particular diagnoses, symptoms,
thoughts, emotions, positive or negative self-evaluations, social roles,
personality traits, physical characteristics, or other conceptualizations
with little or no awareness of self independent of that which is currently
occupying her awareness. The client rarely transitions among content
areas as the situation demands, even when prompted, and often acts
ineffectively as a result. The clients activities are severely limited by

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Experiential Case Conceptualization

conceptualizations
of herself. She cant take different perspectives even
when prompted and doesnt take different perspectives spontaneously.

Self Process Abbreviated Anchors

12345
Experience of self
constrained and in only
limited domains

Experience of self
5 flexible and broad

Frequently gets stuck in


content areas

Transitions easily
among content areas

No experience of self
apart from content

Experiences self apart


from content

Rarely able to shift


perspectives

Readily able to shift


perspectives

Defusion Process Narrative Anchors


A SCORE OF 5
The client almost always experiences a full range of thoughts, beliefs,
emotions, and evaluations without any aspect of experience dominating
control of his behavior, except where such focus is chosen. Stories about
how the world is (for example, about the future, the past, others, or relationships) are held lightly. Stories are rarely rigidly repeated. When the
client does lapse into such stories, he readily recognizes this and lets go
of the story. He infrequently uses exclusive language such as must/cant,
should/shouldnt, always/never, or right/wrong. The client experiences
and describes his experiences without judging, justifying, or explaining. He chooses assumptions strategically because they facilitate valued
living. The client approaches new experiences openly, with expectations
and rules derived from prior experiences held lightly.

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A SCORE OF 3
The clients experience of events is sometimes limited by particular thoughts, beliefs, emotions, and evaluations that dominate control
of her behavior. This domination isnt experienced as chosen. Stories
about how the world is (for example, about the future, the past, others,
or relationships) are sometimes held rigidly. Stories are sometimes rigidly
repeated, but the client moves to another topic or aspect of experience
when directed. She sometimes uses exclusive language such as must/
cant, should/shouldnt, always/never, or right/wrong, especially in the
face of difficulties. The client sometimes judges, justifies, or explains her
behavior. She shows occasional sensitivity to the workability of beliefs
but is frequently sensitive only to the true/false aspects of belief. The
client approaches new experiences with relatively rigid expectations and
rules for behavior, which sometimes persist even if they arent consistent
with the new experience.

A SCORE OF 1
The clients experience of events is almost always limited by particular thoughts, beliefs, emotions, and evaluations that dominate control of
his behavior. This domination isnt experienced as chosen. Stories about
how the world is (for example, about the future, the past, others, or relationships) are held rigidly and often repeated. The client doesnt move
to another topic or aspect of experience, even when directed. There is
much use of exclusive language such as must/cant, should/shouldnt,
always/never, or right/wrong, especially in the face of difficulties. The
client frequently judges, justifies, or explains his behavior. He shows little
or no sensitivity to the workability of beliefs and is sensitive only to the
true/false aspects of belief. The client approaches new experiences with
rigid expectations and rules for behavior, which persist even if they arent
consistent with the new experience.

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Experiential Case Conceptualization

Defusion Process Abbreviated Anchors

12345
Single aspect of
experience dominates
without choice

No single aspect of
5 experience dominates,
except by choice

Frequently judges,
justifies, or explains

Frequently uses must/


cant, should/shouldnt,
right/wrong, and so on

Rarely uses must/cant,


5 should/shouldnt, right/
wrong, and so on

Expectations and rules


limit perspective

Expectations and rules


held lightly

Stories seldom repeated


rigidly

Stories repeated rigidly

Little or no sense of workability of thoughts


1

Rarely judges, justifies,


or explains

Chooses assumptions
5 strategically, with a
focus on workability

Acceptance Process Narrative Anchors


A SCORE OF 5
The client embraces the full range of experience and only rarely
attempts to change the frequency or intensity of associated bodily states,
emotions, thoughts, perceptions, urges, cravings, or memories. The
client rarely insists that an aspect of experience thats difficult must
be eliminated, or conversely that some desired state must be obtained.
The client frequently experiences and describes difficult experiences in
session with appreciation for their richness and gravity. The client almost
always engages easily and openly, and her presentation rarely seems to
be implicitly requesting attention, permission, approval, pity, condemnation, abandonment, or some other social exchange. The client reports
and shows willingness to experience internal and external events in
service of valued living and often freely chooses such experiences. The
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client notices when shes engaged in avoidance in session and opens up


to her experience independently or is reliably responsive to instruction
to do so.

A SCORE OF 3
The client sometimes embraces the full range of experience, but this
may occur only with direct instruction, for a limited amount of time, in
particular situations, or for less difficult experiences. The client sometimes
attempts to change the frequency or intensity of associated bodily states,
emotions, thoughts, perceptions, urges, cravings, or memories. The client
sometimes insists that an aspect of experience thats difficult must be
eliminated, or conversely that some desired state must be obtained. The
client experiences and describes difficult experiences, but sometimes in
a manner thats minimizing, rationalizing, or otherwise disconnected.
The client engages easily and openly at times, but at other times presents
implicit requests for attention, permission, approval, pity, condemnation,
abandonment, or some other social exchange. The client reports some
internal or external events that he isnt willing to experience. The client
may choose some difficult experiences, but this is sometimes in the form
of tolerance or resignation rather than acceptance. The client usually
opens up to his experience when directly prompted, but rarely notices
independently that hes engaged in avoidance.

A SCORE OF 1
The client rarely embraces the full range of experience and never
or rarely without direct instruction. The client often attempts to change
the frequency or intensity of associated bodily states, emotions, thoughts,
perceptions, urges, cravings, or memories. The client frequently insists
that an aspect of experience that are difficult must be eliminated, or
conversely that some desired state must be obtained. Difficult experiences are often described in a manner thats minimizing, rationalizing,
or otherwise disconnected. The client rarely engages easily and openly,
often presenting implicit requests for attention, permission, approval,
pity, condemnation, abandonment, or some other social exchange. The
client reports many internal or external events that shes not willing to
experience. The client rarely chooses difficult experiences, and when she
does, it almost always takes the form of fighting, tolerance, or resignation rather than acceptance. The client rarely opens up to her experience when directly prompted to do so and may actually become more
avoidant.
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Experiential Case Conceptualization

Acceptance Process Abbreviated Anchors

12345
Attempts to change
experience common

Minimizes or
rationalizes difficult
events in session

Describes and
5 experiences difficult
events in session

Implicit requests for social


1
exchange
Many avoided events

Fights, tolerates, or resigns


to difficult experiences
1

5
5

Attempts to change
experience rare

No implicit requests for


social exchange
Few avoided events

Chooses difficult
5 experiences in service
of valued living

Does not notice when


avoiding

No change or more
avoidant with direction

Notices when avoiding


More open with
direction

Valued Living Narrative Anchor


A SCORE OF 5
The client maintains an open posture with respect to values even
in the face of psychological pain. He freely, actively, and intentionally
chooses life directions. His behavior is only rarely organized rigidly by
thoughts and evaluations regarding values. The client expresses a sense
of vitality and purpose in values even when describing painful events.
Values are held flexibly and without defense, in a way thats sensitive
to needs in other domains of living. The client notices and describes a
variety of behaviors that could be chosen in service of a valued direction. The clients behavior is almost always in service of this direction,
even when outcomes are expected to be difficult or unknown. The client
almost always describes his chosen values and degree of valued living
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Mindfulness for Two

openly and without judging, justifying, explaining, or apologizing. The


client usually experiences his values as facilitative of experience rather
than restrictive or burdensome.

A SCORE OF 3
The client chooses direction for her life, but this is sometimes limited
by what is perceived as possible or painful. She expresses a sense of
vitality and purpose in values but is less likely to do so when describing painful events. Values are sometimes held defensively and rigidly,
even when doing so has negative consequences in other domains of
living. The client notices and describes a somewhat limited number of
behaviors that could be chosen in service of a valued direction. The clients behavior varies in how consistent it is with pursuing this direction,
and is often inconsistent when outcomes are expected to be difficult or
unknown. The client sometimes describes her chosen values and degree
of valued living with limited openness, as evidenced by judging, justifying, explaining, or apologizing. The client sometimes experiences her
values as facilitative of experience and but also frequently as restrictive
or burdensome. When directly prompted, the client can sometimes let go
of limitations and make contact with values in an undefended wayher
stories loosen and she shows lessening signs of fusion and avoidance.

A SCORE OF 1
The client rarely chooses direction for his life in an active and flexible way. Most valuing is described as driven by circumstances and much
less by personal choice. He professes no sense or a weak sense of valued
direction; describes valued domains with rigidly held preordained conclusions about outcomes; or professes strong confusion about values. All
of these presentations are held rigidly even when directly probed. The
client expresses a sense of hopefulness and direction in values almost
exclusively when things are going well. This sense of direction is readily
lost when hes confronted with painful events. When values are held, they
are almost always held defensively and rigidly. Behavior shows insensitivity to costs in other domains of living. The client resists discussions of
values and does so only with excessive judging, justifying, explaining, or
apologizing. He almost always experiences values as restrictive, burdensome, impossible, or confusing, or with rigid enthusiasm.

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Experiential Case Conceptualization

Values Processes Abbreviated Anchors

12345
Valued directions rarely
chosen, and limited by
possibility and pain
Valued directions chosen
with defensiveness
Valued directions held
at the expense of other
domains
Few behaviors described
as values consistent

Valued directions
5 chosen freely, regardless
of possibility or pain

Valued directions
5 chosen without
defensiveness

Valued directions held


in a way that doesnt
5
interfere with other
domains

A variety of behaviors
5 described as values
consistent

Behavior more consistent


with expectations for
1
outcome

Behavior consistent,
even when outcome
5
unknown or expected
to be painful
Discusses values and
valued living openly

Resists discussing values


and valued living by
1
judging, justifying,
explaining, or apologizing

Experiences values as
aversive and restrictive of
experience

Experiences values as
5 appetitive and facilitative of experience

Committed Action Processes Narrative Anchors


A SCORE OF 5
The client almost always remains flexible and creative in her pursuit
of chosen valued directions, even in the face of disappointing or frustrating outcomes. The client willingly chooses short- and long-term goals
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that are experienced as consistent with her values. The client can see
and select from many potential goals, both small and large, that are consistent with her chosen life direction. The client notices when her behavior is inconsistent with valued directions independently and without
defense, and returns gently and with intention to commitments. The
client is responsive to direct instruction to notice inconsistency, and is
able to sit undefended in the face of inconsistency and return gently and
nondefensively to commitments when necessary.

A SCORE OF 3
The clients behavior in valued domains sometimes involves attempts
to relieve difficult thoughts and feelings through inaction, impulsivity, or
persistence despite ineffectiveness in pursuing values. Periods of inactivity are sometimes followed by activity that serves to undo and defend
the client from periods of inactivity. The client sometimes responds to
disappointing or frustrating outcomes by questioning his values or capacity to commit, and has some difficulty generating goals that are consistent with his values. The client can sometimes generate an array of
goals small to large, but at other times becomes attached to particular
forms of behavior as the only goal consistent with his values. The client
sometimes notices when behavior is inconsistent with valued directions
independently but may be somewhat defensive or, by contrast, ruminative about failures, making it difficult for him to return to commitments,
even with instruction.

A SCORE OF 1
The clients behavior in valued domains is almost always dominated
by attempts to relieve difficult thoughts and feelings through inaction,
impulsivity, or persistence despite ineffectiveness, or by lurching into
periods of activity. She may actively avoid making commitments or speak
about commitments in the language of must/cant, should/shouldnt, and
never/always. She has great difficulty generating goals that are consistent
with her values. The client is unable to generate a range of large and
small goals, and experiences the goals she does generate as the only goals
consistent with her values. The client is frequently insensitive to times
when her behavior is inconsistent with valued directions or she becomes
rigidly fixed on her failure to maintain commitment. Direct instruction
to notice the inconsistency and return to valued living is usually unsuccessful and may actually bring the client further away from valued living
by precipitating rumination and worry.
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Experiential Case Conceptualization

Committed Action Processes Abbreviated Anchors

12345
Behavior in valued
domains characterized by
1
avoidant inaction, impulsivity, or persistence

Flexible and creative


in valued living

Difficulty generating
goals, and goals limited
and inflexible

Chooses values5 consistent goals easily


and freely

Rarely notices
inconsistency of behavior
with values

Notices inconsistency
5 of behavior with values

No change or further from


valued direction with
1
instruction

Returns to valued
5 direction with
instruction

Much rumination and


worry about commitments 1

Little or no
5 rumination about
commitments

AN EXPERIENTIAL WAY FORWARD


It would be inconsistent with the core ACT model to imagine that information alone wont move clients but will move therapists. Merely understanding the phenomena aboveknowing that they exist and what they
look likeisnt likely to have profound effects on your own behavior as a
therapist. In the preceding pages, I offered you some moment-by-moment
patterns that are common ways we lose contact with the present moment
and diminish our effectiveness. As with clients, the most potent intervention wont be the gathering of information.
ACT is an experiential approach to behavior change. Its the rich
interaction of information with experience that will make us more effective as therapists.
In the next chapter, Ill outline a set of exercises that you can do to
make experiential contact with your own barriers to being fully present
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Mindfulness for Two

to clients. The exercises are an essential part of the approach. They


provide an opportunity to learn about and practice ACT principles. The
impact of the exercises will be twofold. First, theyll soften your approach
to clients. If you can open up to your own deepest fears, breathe them in
and out like air, and sit with them in kindness until running isnt necessary, youll have much more heart for the hard things you ask your clients
to do. Second, if you can meet your worst fears with equanimity, youll
be able to sit in the presence of your clients in a way that opens you up
to the subtle ebb and flow of their behavior and thereby put yourself in a
much more effective place from which to work on their behalf.

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Chapter 8

Making Experiential Contact


with Mindfulness

Simple information about what keeps you and your clients from the
present moment is of extremely limited use. Before jumping from a boat
and swimming to shore, you might know that you need to learn how to
swim. However, knowing is not swimming. Swimming comes from practice at swimming.

THE POVERTY OF KNOWING


Knowing just isnt enough. Making the sort of discriminations that Ive
been describing throughout this book will take practice. Some of the
practice will involve watching and listening to sessions with clients and
actually making these discriminations. But central to what Ive been
writing about here are the discriminations youll need to make in your
own behavior. In order to do this, you need to somehow create experiential preparations that allow for close examinations of ACT processes
within structured interpersonal interactions. Throughout the text, Ive
offered little exercises to help you make contact with ACT-relevant processes. In this chapter, these exercises move solidly into the realm of the
interpersonal. Because these processes, as they play out in interpersonal

Mindfulness for Two

interactions, are central to the doing of therapy, this might be the most
important chapter of the book. It contains far less information than any
other chapter, but far more training experiences that provide a place to
put those principles into practice.
What follows is a series of three exercises. They begin with a very
simple one, Sweet Spot, in which the content is pleasant and your activities are pretty limited. The next exercise, Client Descending, involves
painful content but still a quite limited set of activities. Finally, Ill introduce the Experiential Role Play, where the content is difficult and the
interaction is decidedly more complex. Ill describe several variations on
the Experiential Role Play Exercise, including its use as a way to learn
and do case conceptualization in an experiential context. All of these
exercises require at least one other therapist. Ideally, youll have a total
of three or four therapists working together in order to get the most from
the Experiential Role Play.
Its fair to warn you that you wont like the restrictions I place on
your behavior during these various exercises. The exercises are a special
preparation that makes processes apparent that are typically invisible to
us. Just as in medicine, where tissue stains and dyes can sometimes bring
physical features into high relief, these exercises are designed to bring
psychological processes into sharp, bold resolution.
For example, in Sweet Spot and Client Descending, I impose turn
taking, and silence for the partner whos not speaking. Theres no
question-and-answer exchange allowed in these two exercises. Likewise,
I restrict other nonverbal social exchanges, such as nodding and smiling.
I also restrict problem solving in both of these exercises. Finally, Ill
impose hesitations and silent pauses into the exchanges. In the third
exercise, the Experiential Role Play, I allow questions and answers, but
I enforce adherence to the assigned role (either therapist or client) and
restrict stepping outside of the role during the exercise. I also impose
periods of silence.
I promise that youll find these impositions intrusive and uncomfortable. And I implore you to hold to them. If you dont for some reason, a
good deal of the exercises potential for instruction will simply vanish.
These role plays have been road tested on literally thousands of therapists and will do their work. Try the exercises as described. Hold to the
structure of the exercise. If you find over time that you wish to modify
them, feel free to do so, but give them a try as is before you do.

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ENTERING A DIFFERENT SORT OF


CONVERSATION
What I want with my clients are significant conversations, conversations
that can change livesboth theirs and mine. When I say change, I
dont mean from something bad to something goodfrom a bad
them to a good them, from a bad life to a good life. We have but
one lifethis life, this very life. Conversations about whether a life is
good or bad or whether a person is good or bad or worthy or unworthy dont interest me much. Back and forth they go, but to what end? I
havent noticed these conversations taking me nor my clients anywhere.
Ordinary conversations come so naturally to us. One doesnt need a
therapist to have one of these conversations. Step into any bar. Buy the
person next to you a beer. Complain about something, almost anything
really. See if he isnt willing to join you in that complaint.
Oh, you think your boss is bad!
Well, then my wife said
Nothing ever really goes right for me either.
And on and on. If your newfound companion doesnt join you in
your misery, hell almost certainly favor you with a hollow reassurance
that things will get better. Ask him not so kindly for an alternate view,
and hell start giving advice. The conversations differ in comfort level
but little in function.
Perhaps you can recall certain conversations youve had in your own
life, though, that shook you, that altered your fundamental relationship
with the world around you. Perhaps the conversation were having right
now could be like that. Perhaps the next conversation you have with a
client could begin such a process.
Im not shy about telling clients that Im interested in life-changing conversation with them. Part of the task at hand will be to distinguish two kinds of conversations. One type of conversation is all about
limitationsconversations about what can be expected, hoped for, imagined, about what is realistic or deserved or could be gotten away with. But
dont you want more than that? Dont your clients long for more? Theres
a second kind of conversation. Its a conversation about possibilities.
Its a conversation about that which we long for but perhaps cant even
namea sometimes inscrutable more. Were not used to more, except in
the crude material sense. Were used to wanting more house, more car,
more money. Even when we want more of nonmaterial thingsto be

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loved, understood, appreciatedthe more often has a clutching quality


thats not unlike the desire for a new car.
Theres little outside of religious conversations, though, that fosters
a careful discernment of the direction ones life might take. Even in religious conversations, such direction is too often formulized. Im interested
in conversations within which we can hear the resonance of the very
world and the resonance of our own lives in that worldconversations
in which we can hear, really hear, the depth of love that has gone unspoken, perhaps even unfelt, the dreams and desires that remain tucked
awaysignificant conversations. These exercises provide a simple, but
not easy, way into such conversations.

THE SWEET SPOT EXERCISE


Think of a moment in your life that was sweet. Sounds simple enough,
right?
This exercise involves two participants who exchange the tasks of
speaker and listener. You can do it with up to four people if two of them
take the role of witnesses, unnerving people whose job it is to silently
observe the speaker and listener exchange. The addition of witnesses to
the exercise is a recent one, which I think changes the dynamic of the
exercise dramatically for the better. If you can, I strongly urge you to try
the exercise with witnesses.
For content, I ask participants to think about a specific sweet moment
in their own lives, past or present. The exercise involves a meditation on
this sweet moment followed by a period of speaking and listening in turn.
The purpose of the exercise is to cultivate mindfulness for two in a very
simplified interpersonal interaction.
A script for the induction, or introductory phase, for this exercise
follows. I didnt include a script of anyones sweet spot. You can easily
supply that yourself, and theres a complete video clip of the exercise
included on the disc that comes with this book. Also, theres an audio
recording on the disc that you can use in a practice group to conduct
the exercise. If you do try the exercises with the audio recording, make a
point of honoring the instructions to pause and let your voice fall away.
When I lead this exercise in workshops, I break up the conversation at
random intervalsand Im very strict about not letting the conversations continue when I do. The disc is actually very faithful to the live
experience in this respect.
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Making Experiential Contact with Mindfulness

Sweet Spot Exercise Structure


The basic structure of the exercise follows. A more elaborated description of the structure and of what Im looking to find in the moment of
sweetness can be found in the script of the exercise below.
1. Introduce the idea of a sweet spot.
2. Get participants paired up. If you have witnesses, the witnesses should sit directly across from one another and the
speaker and listener should likewise be sitting directly across
from one another. The participants should face each other
directly. They should sit near one another to hear even if
speech becomes quite soft.
3. Instruct the roles for speakers, listeners, and witnesses.
4. Listeners: The job of the listener is to simply appreciate the
sweetness thats being expressed. In chapter 1, I spoke of
clients as sunsets versus math problems. In this exercise,
the pitfall for the listener will be to try to understand what
the speaker is describing. I will ask, for the purpose of the
exercise, that you let go of understanding. You may pick
understanding up again later. For now, when you find yourself trying to understand, just gently let that go for the time
being. Your job is just to observe this sunset before youa
human being in the simple act of expressing sweetness.
5. Speakers: The pitfall for the speaker will be to explain why
something is sweet. No explanation is needed. You should
let go of explanation when it arises and gently return your
attention to your own experience of sweetness and to letting
that sweetness pour forth. What were after is not explanation, just expression. Allow yourself to be a sunset. Let the
listener be an observer of that sweetness you have known.
Ive done this exercise with people speaking different languages and it remains effective. Gently let go of concerns
about being thorough or coherent.
6. Witnesses: The task for the witnesses is to watch the pair of
sunsets before you. Allow yourself to notice the ebb and flow
of the presence of both the speaker and listener. Witnesses
will be prey to the same comings and goings as the therapists
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Mindfulness for Two

and clients. When you find yourself in analysis land, gently


return to the interaction. Appreciation is the core task.
Because of the intimacy of the exchange between speaker
and listener, witnesses may feel inhibited in looking directly
at the speaker and listener. Please gently notice that reluctance and allow yourself to watch. Youll see subtle shifts,
and we want to cultivate an appreciation for those shifts.
7. Decide in advance who will be the first speaker and listener.
There are no breaks during the exercise. Transitions from
one speaker to the next are not punctuated by conversation
or debriefing. Protect the quiet state between shifts in role.
8. Get participants settled in and then lead the Sweet Spot
Exercise.
9. Have participants open their eyes gently and in silence.
10. Instruct the first speaker to begin speaking. Caution him to
intentionally bring a very slow, mindful pace to his expression of sweetness.
11. Stop the speaker after a couple minutes. Have him rest in
silence for a few moments, notice the busyness of his mind,
pause again, and come even more gently back to the task.
12. Stop the speaker again and have both speaker and listener
allow their eyes to close. Take about two minutes during
which the speaker, listener, and witnesses (if any) rest in the
sweet moment.
13. Have the speaker and listener switch roles and repeat the
process above.
14. Debrief using the debriefing instructions that follow the
exercise below.
If youre leading this exercise, you should read the exercise slowly,
mindfully, and gently. Listen to your own words one by one. Pause regularly and let your own words settle around you. It will help you catch up
with yourself. It will help you to set the pace for the exercise. Also, do
note that the script that appears below is not a word-for-word transcription of the guided audio that appears on the disc.
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Making Experiential Contact with Mindfulness

The Sweet Spot Exercise Script


Im going to lead you in a little eyes-closed exercise. Ill ask you to bring your
attention to a sweet spot in your own life. So let me give you an example. It
can be a very simple sort of thing.
[Use your own example of a sweet moment. Let yourself settle into it
even as you tell about your sweet moment. Allow yourself to be saturated
by that moment in each word of its expression.]
An example Ill give is something I experienced with my thirteen-year-old
daughter. For those of you who have teenagers or grown children, you know
what I knew during this sweet momentthat the writing was on the wall.
Other people were going to start to be much more interesting than me at any
minute. So in my moment of sweetness, Im savoring those last drops of being
the apple of my daughters eye.
On Sunday mornings a long time ago, my family and I used to sit with a
congregation of Quakers. The children would sit with the adults for the first
ten minutes or so before going off to childrens meeting.
I would sit in the big easy chair in the corner and my daughter would plop
down on my lap and lay her head on my chest. She is freshly showered and I
can smell her hair as shes sort of nestled there. Theres no place to go. I can
feel heryou know, close to me there. Sometimes its just the best ten minutes
of my whole week. Its just perfect.
There is nothing that moment needs. That moment is complete.
So Ill ask you to think about some sweet spot. It doesnt have to be like
mine. It can be some thing very simple. But think about something specifica
specific instance of something sweet. It could be like your first cup of coffee in
the morning, like on Sunday morning when you lay out the paper and take
that first sip. Or it could be anythinglike watching a sunset or paddling a
kayak. Sometimes when youre watching your kids as they play, there are these
times when they completely dont see you watching them, and you really see
them.
I would like to invite you to encounter that sweet moment. And then Im
going to ask you to open your eyes. Youll be sitting across from your partner.
There are going to be two jobs that you do.
The first job is to just express this sweet moment, to just give voice to
it. Heres one of the problems that will show up for you. Like I said, youll
encounter problems. The problem here will be that youll want to explain
yourself. Like youll think, Im not really explaining myself so that the listener
really gets how sweet this is for me. Youll want to solve that problem. So if you
find yourself doing that, you have the same job you would have, say, if you
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Mindfulness for Two

notice yourself making a grocery list while doing sitting meditation. Your job is
to notice that and then gently come back to your breath.
Here youre just giving voice to this sweet moment, letting it pour from
you. Just like you took a glass of water and let that water pour out. Just like
that. If theres any effort involved, just notice your efforting, and just let yourself go silent and come back to giving expression to your sweet moment.
Your partners job is to appreciate. And for appreciators, the pitfall is trying
to understand. And another pitfall is trying to make sure that the expresser
understands that you understand. Appreciators will want to nodlike I get
it, Really, Right. Because think how uncomfortable the expressers would
feel if they didnt get that you got it. You know, here they are telling you about
this wonderful thing, and it just goes in one ear and out the other. How awful
would that be for them? So youll feel inclined to solve that problem by reassuring them that you understand.
I want you to notice how much you feel like you have to nod and smile.
Theres nothing wrong with scratching if you have an itch. But theres something that shows up in a meditation if you dont itch that scratchif you just
notice it, if you say yes to it. So Im going to ask you to just say yes to these
things that will show up for you.
You might say to yourself, I dont know if I really get this. And then youll
try to noodle it out. If you find yourself efforting and trying to understand,
just notice that. Notice the efforting and then gently bring yourself back to
the person whos sitting across from you. Just like watching a sunset. You
dont need to evaluate it. You dont need to understand. How many people
understand the physics of light refraction? Not so many. But are you able to
appreciate a sunset? Sure.
Im going to ask you to go silent. No talking in between here. We can talk
later. Just sit and be with the person across from you. After a while, Ill ask
the next person to go. When I do, you just switch jobs. Then Ill ask you to go
silent again. I dont want any conversations to intervene here. Ill ask you to
just sit with the person for a moment. Then Ill ask you to acknowledge your
partner and well come back together again.
Okay, so lets occupy the room.
Now during this session Im going to be coaching you. I can almost assure
you that another problem will occur. Youll think, Gee hes annoying. I was
really doing well here, but now hes bothering me. If you notice that, just notice
it and come back to your task. Im going to ask you to stop talking at certain
points, but you wont be done, and that will present itself as a problem. I want
you to just notice that and come back to your task. So if youre expressing and
I ask you to stop and let yourself grow silent for a moment, and you notice the

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Making Experiential Contact with Mindfulness

thought But Im not done, then just notice that and let the expression continue
even though the words stop.
Allow yourself to sit comfortablymaybe with your feet on the ground.
You wont need any paper of pencil or anything like that. Just gently, gently let
your eyes close.
Id like you to begin by noticing the different sounds in the room. Imagine
that you have a sort of checklist. Begin with the most prominent sounds, and
just as you notice them, imagine that you check them off the list. See if you can
listen for smaller more subtle sounds. You might hear the sounds of vehicles
outside, the sound of a jackhammer. If you listen carefully, you might hear the
sounds of people around you. Breathe.
Begin to draw your attention to your own body. Slowly begin to notice
the place where your body makes contact with the floor, with the chair. And
breathe. Notice especially the little places where you can feel the transition in
that contact, the very edges of the place on your back thats touching the chair.
See if, in your minds eye, you can trace that very edge. See if you can begin
to notice the very small details in sensation that tell you this part is touching,
that is not. And breathe.
And now Id like to draw your attention to your own hands. Id like you
to start to notice the temperature of your hands. Maybe you can notice that
some places on your hands are a little warmer than other places. See if you
can notice the little details of sensation of those transitions from places that
are little warmer to places that are a little cooler on the skin of your own
hands. And breathe.
See if you can notice the sensation of your blood pulsing in your hands.
Notice just where in your hands you can feel that. Now Id like you to take
just a couple of nice slow breaths where you notice the details of the inflow
and outflow of your own breath. Let your lungs fill completely and empty
completely.
Now Id like you to imagine that in front of you there is a file cabinet.
Now imagine that you open the drawer and reach in and withdraw a picturea picture of you during that sweet moment. Let yourself draw that
picture up from the file cabinet and feel it in your hands. Let yourself look into
that face of yours in that picture and let yourself notice the details surrounding
you. Notice the look on your face. And now I want you to imagine as if your
awareness were some sort of liquid that could be poured into that you in that
picture. So imagine that now you are beginning to pour into the skin of that
you in that picture at that very moment. See if you can let yourself emerge in
that place at that particular moment. You can imagine opening your eyes in
that place and kind of let yourself see what you see there. Let yourself notice
the sensations that you feel on your own skin in that place. If youre outdoors,
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perhaps you feel a slight breeze. If youre with someone, you might feel the
warmth of his skin against you, the scent of her hair. Let it be as if you could
just breathe that moment in, as if each breath just filled you with the sweetness of that. Let it be as if every cell in your body can feel what it is to be in
that place.
Just take a moment to luxuriate in that presence. And now Im going to
ask you to gently, gently let your eyes open. I dont want anyone to speak yet.
Let yourself look into the eyes of that person who is sitting across from you
and let yourself notice that there is a person sitting right across from you who
has known sweetness. Just look into those eyes, and see if you can see not the
person present but the person who has known sweetness behind those eyes.
Now the person who is going to go first, I want you to just gently let that
sweetness fill you up slowly like some liquid, and when youre ready, I want
you to gently, gently begin to speak and give expression to that. Let the person
across from you hear, feel, and see that sweet moment. Stay with it. The
person who is appreciating, there is something there. Just notice the color and
nuance of it.
[Expression begins.]
Now Im going to ask you to gently grow silent, but see if you can just
let that sweetness continue to pour from you. Look in these eyes across from
you. Now were not going to switch yet. Im going ask the same person to start
speaking, but before you start, I want you to notice if there was any urgency
to explain yourself, any push, any effort. Ill ask you to gently notice that and
let go of that effort. And the same person again just gently come back to that
expression. Just let it come from you. Just let it flow.
[Expression resumes.]
Once again, gently, gently let yourself go silent. Look once more into the
eyes of the human being across from you who has known sweetness. Now Im
going to ask you to gently close your eyes for just a moment. The person who
was appreciating, Ill ask you to recall that sweet moment of your own. Just let
yourself see it. And let yourself be poured into that moment until you can feel
it in your very skin and your breath. And then, when youre ready, just gently,
gently open your eyes and look into the eyes of that human being across from
you. I want you to go gently as if you were walking through a forest. If you
walk very quietly, you might see things that you would miss if you hurried. So
in the gentlest way you can, just let that sweet moment be expressed.
[Expression begins.]
Now Im going to ask you to pause. Just let that sweetness fill you. Let it
pour from you with no words. Listeners, stay with your partners eyes. There
is a person there who has known sweetness right there. There she is. Then
Ill ask you to gently come back to the task. Just let it come. If you notice any
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effort at all, see if you can let go of that. And if youre appreciating and you
find yourself trying to understand, see if you can just let go of the trying and
just let the moment be poured forth into you as if you are a vessel. So gently
come back to it.
[Expression resumes.]
Ill ask you to just gently, gently let yourself grow silent. Just take a
moment and look into the eyes of that human across from you. Look at the
person behind those eyes who has known sweetness like you, who has known
life. Just look a moment into those eyes. Behold.
[Pause for a few moments.]
Now gently acknowledge your partner, and well start our debriefing.

Debriefing the Sweet Spot


After completing the exercise, debrief it as follows. There should be
no break between the exercise and the debriefing. Come very gently to
the debriefing. Dont rush. Let your words come one at a time and attend
carefully to your pacing. See if you can bring that mindful posture into
the debriefing. Especially watch your transition through the questions.
Read the question and then take a moment of silence to sit inside the
question before you begin to answer. Notice your own urgency to get on
with it.
1. Take a few minutes and focus your attention directly on your
experience. If you notice any theoretical analysis appearing in
the conversation, please let go of that and come back to the
experience.
a. What was the quality of your experience with your
partner?
b. What impact did the exercise have on your sense of connection with your partner? Do you feel closer to or further from
your partner?
c. Did you have the experience, even momentarily, of truly
being seenthe experience of being a sunset rather than a
math problem?
d. Did you have the experience, even momentarily, of truly
seeing another personthe experience of seeing a sunset
rather than a math problem?
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e. How was that experience?


f. How common is that experience in your life?
2. Next, were going to look at the experience through the lens of
the hexaflex. Again, gently breathe. Well bring mindfulness to
analysis. It can be done. Just slow, slow down. Go gentle. If you
find yourself being caught in the analysis, noticing that hook is
part of the exercise. Whichever partner notices, please make a
quiet request for a mindful moment. Let go of analysis and come
gently to your breath, even for just a half a minute, and then
gently rejoin the analysis.
3. Next, use a hexaflex worksheet to examine your experience,
looking through the lens of the hexaflex. All components of the
hexaflex emerge in this exercise. See if you can characterize your
own comings and goings in each dimension.
a. Present moment: Note the number of times you found
yourself out of touch with your partneroff in your head.
What were you doing while you were gone? What did you
notice when you returned? What happened in your relationship to your partner when you were truly present and
when you were gone?
b. Acceptance: When you were gone, what were you doing?
Were you trying to get it right? What was unacceptable that
you were working on? Were you rebelling against the instructions? Were you generating alternative (and improved) ways
of doing the exercise? Thinking that you picked the wrong
sweet spot? Comparing yours to the other persons? Notice
your own discomforts and the effort you put into them in
this simple, sweet, short exercise.
c. Defusion: Take a moment and note the stories you told
yourself during the exercise and the ways that they captured
your attention during the exercise.
d. Self: Notice the ebb and flow of you-as-content and the you
that was just there, present, appreciating, and appreciated.
Note the you who showed up when you let go of stories,
struggles, doing it right, comparing, and evaluating.

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e. Values: There are implicit values present in this exercise.


First, theres the value youre pursuing that put you in this
exercise. Youre not here by accident. I assume that you
value entering more significant present-moment-focused
conversations with your clients. In a more general sense,
note that there is another human sitting across from you in
this exercise and that you value being there for that person.
Take a moment and notice the ways these values were lived
in the short minutes of this exercise.
f. Commitment: If you noticed that you went away in the
exercise, note also that you returned. Why did you return?
It was not merely to follow instructions. Notice what it
meant to you to come back. Notice what those moments
of appreciation and being appreciated meant to you. Was it
not the case that each of your own gentle returns was a lived
example of committed action? What would it mean to you
to practice that gentle return and to bring that return into
the room with your most troubled clients?
Youll find a version of this exercise that can be done with individual
clients on the DVD-ROM. That variation involves you leading the exercise and taking on the role of the appreciator. In that version, you can
also coach slowing down of the client and you yourself can express appreciation for what the client has expressed. The exercise is useful in your
supervision group, but it can also be done in group therapy with only
minor revisions. As is done in individual therapy, the therapist should
lead the exercise and coach all of the participants to slow down, pause,
linger, and return to the task. An additional variation that can be used
both with clients and with your consulting group is to do the exact exercise format with different content. The same exercise can be done as the
Sad Spot, the Excitement Spot, or the Fear Spot, for example. Joanne
Steinwachs, a friend in Denver, has led an entire therapy group in which
they did variations of the exercise each week of the group.
For the purposes of this book and this chapter, the exercise prepares us to examine all areas of functioning on the hexaflex, to practice
mindful use of the hexaflex worksheets, and, importantly, to cultivate
our skill at making the gentle return back to our clients and perhaps
more broadly to our own lives.

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THE CLIENT DESCENDING EXERCISE


The next exercise imposes the same restrictions and the same roles.
As difficult as remaining present is with sweet content, the challenge
with difficult content is much greater. This exercise brings us a bit closer
to what we face in the therapy room. The restrictions are still in place
because they will allow us to watch very directly, unobscured by our busy
activity as therapists, the kinds of reactions we have in therapy. This
exercise calls us to sit in the presence of pain, both our own and that of
our partner in the exerciseor, if we are witnesses, to both.
In this exercise I ask therapists to think of a specific client for whom
they have a concern. Participants may also select a person who isnt
a client for whom they carry a concern. Ive even had people do the
exercise using themselves as the subject of the exercise. Using a difficult
client, however, is the standard. Prior to the exercise, I inform the participants that Im going to ask them to watch the client descend to the
depths over a long time period. Ill ask them to watch the descent and
imagine that theyre completely incapable of stopping that descent. I
ask them to stop just short of the clients death. Perhaps there are things
worse than death, like standing on the edge of it until the last day of life
with no respite.
The exercise is hard, and therapists shouldnt do this for no reason.
We do it because when were in the presence of such pain, were extremely
prone to work at making the pain stop. As described throughout the
book, behavior under aversive control tends to be less flexible and less
sensitive to aspects of context other than the aversive. Under such conditions, working with our most difficult clients, we need maximal sensitivity in order to see small shifts in their responding and in our own. The
exercise doesnt ask participants to accept the fact of a clients descent,
only the experience of it in the exercise. The exercise allows us to practice acceptance and mindfulness in the presence of extraordinary pain.
If we can cultivate such mindfulness, were more likely to better serve our
clients. The exercise will also provide many more opportunities to watch
clinically relevant ACT processes that will certainly emerge in session.
As in the Sweet Spot Exercise, the person who isnt speaking has the job
not to intervene. In some ways, this is difficult, because all of your clinical
repertoires will come to the fore. In some ways, its simpler than working
because it frees you to just be a witness to your partner and to your own
processes.

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The Client Descending Exercise Structure


This exercise has precisely the same structure as the Sweet Spot; the
only difference between the two is the introduction to the exercise and
the content of the mindfulness exercise. Apart from this, the restrictions
on speaker and listener and in regard to turn taking are identical to those
in the Sweet Spot Exercise.
If youre leading this exercise, you should read the exercise slowly,
mindfully, and gently. Listen to your own words one by one. Pause regularly and let your own words settle around you. It will help you catch up
with yourself. It will help you to set the pace for the exercise.

The Client Descending Exercise Script


Just allow yourself to settle into your chair and breathe. See if you can begin
by letting your attention come to all the activities that brought you here this
morning. Id like you, as if you could watch it in a movie, to watch yourself
get up this morning, preparing yourself to leave. And maybe you would notice
some busyness that you had, thinking about what was coming. So just breathe
and take a moment and let yourself notice that sort of buzz of activityas if
you could feel it in your own skin, a sort of physical buzzall of that movement and activity in parts of your body.
And breathe. Just notice where you feel that in your body, and then begin
to let your attention follow you through your activities that brought you here.
Let yourself notice little places along the way: as you found your way to the
building and up into the room, taking little stops along the way to notice the
things that you saw. And the preparation to get yourself seated in these chairs.
And settling in and preparing to do this piece of work. See if you can notice
any nervousness or anticipation. And let yourself just breathe that in and out,
and see if you can locate where you feel that in your body. And allow your
breath to just permeate that sensation, to just flow through it. Begin to notice
what its like to sit right here in this very chair, at this very moment. And
breathe gently, gently.
Let your awareness come to rest on your breath. Take just a moment
to notice the tiny sensations that come with the inflow and outflow of each
breath. See if you can notice tiny differences in sensation between the inflow
(cool) and the outflow (warm.) Just take a moment to appreciate your own
breath, that through all those activities this morning, your own breath was
there, waiting for you. And let each breath invite you into this very moment.
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Let each breath invite you to notice your own body, your own person, sitting
right here, right now.
And if you find yourself getting ahead, just gently, gently come back to
the sound of my voice. Let your breath invite you back into this moment. And
then follow the next instruction that I ask of you. And breathe.
And Id like you to imagine now that, in front of you, theres a file cabinet.
Before you reach for it or open it, I would ask that you call to mind a client
who youve worried about, a client who maybe youve wondered whether you
could helpperhaps a client that you go home on weekends and you wonder,
is this one more weekend he spends in isolation? Will you even see him the
next week? Will he give up? Will he give up on you? On himself? And just let
yourself breathe then in and out for a moment.
And Id like you to let that file cabinet before you fill with photographs of
that client. And Id like you to imagine that you reach out so that your hand
just barely touches the handle of that file drawer. And let yourself feel your
fingertips, as if they were just barely touching the drawer. And breathe.
And let yourself know what is in that drawer. And gently, gently draw the
drawer open, and allow yourself to hear the sound of that drawer slide open.
And breathe. And imagine that you could reach in, toward the front of the
drawer, and place your fingertips on a photograph. Ill ask you to imagine that
you draw that photograph out of the file drawer. Listen to the sound of it as
you draw it out. And then allow it to come to rest in your lap. And let your
eyes begin to move across that image. And Ill ask you to let yourself see, to
let an image form there of your client as he is right now. It could be a picture
of him somewhere in his life or in your office. And let yourself see, in that
picture, the way that client holds his body. Is there tension in his body? Does
he look closed off? Or does he in some way look as if people might walk by him
and not even notice the sort of suffering that he has? But Ill ask that you let
yourself see that.
So let your eyes linger on that clients face and see if you can see in that
face, in those eyes, that person. And see that struggle that others may not see
but that you know about. And just take a moment and let yourself breathe
that struggle in and out. You can hear the echoes of it, maybe, from the sessions youve had. Hes begged you for answers. And see if you can see that
longing in that face. What is it that he hopes for in his life, if he were capable
of hoping? What does he long for? Can you let yourself see that?
And I want you to begin to notice how much you want to be able to reach
in there and help him, to reach in and make a difference for him. And let
yourself just breathe your own longing in and out like air. And Ill ask you, beg
you, to let it be so that no matter what you do, no matter how hard you try,
that helping him is beyond your grasp. Like someone falling down the stairs
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whos just out of reach. Where you reach out toward him to stop that tumble,
but you cant quite reach far enough. As if, when he begins to fall, you can
see that look in his eyes reaching out toward you and knowing that theres no
reach quite far enough.
Just linger at that cusp right there. Let yourself look into those eyes that
have that longing. Dont turn away. Just let yourself rest there for a moment and
breathe that longinghis longing and your longingin and out. And breathe.
And take one last look at that face, and allow that picture to be lifted
from your lap. And one last look. And let it drop gently, gently into the drawer.
And then I want you to just rest a moment and let what you just saw gather up
around you. Let yourself breathe in and out your own powerlessness. Maybe
your own insecurities about whether you could make a difference.
And then Ill ask you to reach in again, and Ill ask that you pull a photo
out that is ten years from this day. And if youre afraid this client is going to
die, I want you to let him still be alive. So, if hes someone who wants to die
now, let it be that that wanting to die just stretches out for ten more years, and
he carries that weight.
And draw that photograph of him out of the file drawer, and let yourself see
in that photo, as you carry it gently to your lap, what that face looks like after
ten more years of paying that cost. No one wants to look at him, but would you?
Let me invite you to just breathe him in and out. Let yourself see what ten more
years looks like written on that face. Linger on those eyes for a moment. Let your
awareness stretch out into his life and see all the costs that hes paid over those
ten years. Are his children lost to him? Partners? How many nights and days has
he spent alone? Let yourself see in those eyes that person who hoped something
could be different but maybe knew that it would go just like this.
Let yourself imagine it was as if you could reach out toward him, to stop
that tumble, but no matter how far you reached, no matter how hard you
tried, you couldnt prevent that tumble down. And breathe gently.
And if you notice yourself wanting to turn away, just gently turn back
and let yourself look into those eyes and see those costs written in his eyes.
And breathe.
And I would like you to just imagine now that you take one last look at
that image and let it slip gently. See if you can notice that you almost dont
want to let him go. But Ill ask that you do let him go and let him slip, slip back
into the file drawer. And let yourself feel the weight of those ten years of costs.
And breathe.
And now Im going to ask you to reach far, far back into the file cabinet.
And Im going to ask you to pull a photograph from the back of that cabinet
that shows that client on the very last day of his life, in his last hour. Let yourself draw that photo gently up, and bring it to your lap, and cradle it there. See
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if you can hold that photo as if it were on the most fragile sort of paper. And
let yourself look down into that face that has known a lifetime of costs. Let
yourself see that person as he takes that last hour to look back over his own
life at the things he had hoped for. There it is in his face. How many days has
he paid that price?
See if you can remember back to when you had hoped to reach in there,
how much you had wanted to make a difference for him. And let it be so that
no matter what you did, no matter what you said, that he slipped away and
found himself on that last day. How empty is that life? How painful? And how
it is written in those eyes?
And Ill ask that you honor him by being present in his last hour. Just let
that last hour saturate you, so that when he passes, someone will have known.
Someone will have known, someone will have cared to know. Would you be
his witness so that when he passes, someone knows? And breathe, breathe.
And as you breathe, just see if its possible for you to say yes to that suffering. To just allow it to be there and, for just a moment, to let go of the struggle
with that. To just let it saturate you.
And now Ill ask you to take that photo, and with the most gentleness
you can bring to it, take one last look at it, let yourself look one last time in
those eyes so that someone saw them, and let it slip gently, gently back into
the drawer. And place your hand on that drawer, and let yourself notice that
sound as the drawer goes gently closed and comes to a stop.
And Ill ask that you take a moment to just breathe in and out what you
saw. See if you can let go of any struggle with that for a moment.
Im going to ask you in a moment to open your eyes, and when I do, Im
going to ask that you listen to my coaching. And what I would like you to do
is this: dont explain the concern you have but let it be expressed as gentle as
water being poured from a jar. So if you find yourself trying to get it right or
make sure the other person understands, I want you to honor that person you
witnessed by just gently coming back to giving expression to that concern that
you carry and to that decline that you saw. Let yourself be the voice for that.
Im going to give you just a moment to linger and be saturated by what
you witnessed. And in a moment, Im going to let you open your eyes.

Debriefing the Client Descending


Use the same debriefing structure for the Client Descending as was
used for the Sweet Spot Exercise.

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EXPERIENTIAL ROLE PLAY EXERCISE WITH


CASE CONCEPTUALIZATION
The last of the exercisesthe Experiential Role Playbegins with the
Client Descending Exercise. Instead of expressing and appreciating
the concern for the client, the pair moves immediately from the Client
Descending Exercise into a role play. At the end of the exercise, just after
participants see the client on the last day of his life, I ask the participants
to imagine placing that photo back into the file drawer and then imagine
seeing the client in a therapy session the next week. Therapists are asked
to imagine that their awareness is poured into the skin of her client.
When the pair opens their eyes, the person who has been designated to
go first plays her own client. Again, the details of the exercise are in the
script below. In addition, a version of this exercise can be found on the
disc that accompanies the book.

Experiential Role Play with Case


Conceptualization Structure
The following role play should come after having done the Client
Descending Exercise.
1. Have participants provide a thumbnail description of the
client and decide who will be the client and who will be the
therapist in the first round of the role play.
2. Reestablish the focused mind-set you fostered during the
Client Descending Exercise.
3. Instruct the participants to imagine themselves poured into
the skin of their client.
4. Instruct participants that when they role play therapists, to
bring the same mindful presence to bear in the clinical conversation. Warn them that this is more challenging when
the therapist gets to talk. Advise them that you will create
mindful pauses in the instruction, but that they should also
take them spontaneously.

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5. Instruct the participant playing the therapist to intervene


with the participant whos playing the client.
6. Stop the therapist and client after a couple minutes. Have
them rest in silence for a few moments, notice the busyness of their minds, and pause again, then come even more
gently back to the task.
7. Stop the therapist and client again and have both allow
their eyes to close. Take about two minutes during which
the person who was the client sits in silence and notices the
qualities of that experience.
8. Have the therapist and client switch roles. Participants
playing the therapist should be instructed to pour their
awareness into the skin of their own client.
9. Repeat the role play as above.
10. Debrief using the debriefing instructions that follow the
Sweet Spot Exercise.
11. Make a case conceptualization using the hexaflex worksheets and rating scales. Add variations:
a. The simplest variation is this: After the role play has
been going on for a while, have the therapist and client
switch roles. By the time the role play has gone on for
ten or fifteen minutes, the person who has been playing
the therapist will have a good feel for the client and
should be able to play the client reasonably well. This
casts the actual therapist for this client back into the
role of the therapist again. This shift in perspective can
considerably enhance your flexibility as a therapist, will
cause you to see your client in a different light, and will
alter your relationship with your client.
b. If you have witnesses, rotate all roles clockwise. Let the
witnesses take on the roles of therapist and client. As
in the first variation above, shifting to the observer role
enhances flexibility. It allows you to see yourself and the
client through different eyes.

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Experiential Role Play Exercise Script


Just let your eyes gently close. I want you to just take a moment and let your
attention gently come to rest right now on the inflow and outflow of your
breath. And if you find yourself thinking forward to the exercise, gently let
go of that and notice again that in the midst of all that mental activity, your
breath continues. And no matter how busy you get, it flows like a river. It
requires nothing of you. Just let yourself linger for a moment inside that steady
stream of inflow and outflow of breath. Each time you find yourself drifting away in thought, into the future or past, just let that steady inflow and
outflow draw your attention gently back. Allow yourself to just notice all of
the tiny sensationsin your lips, your mouth, the gentle rise and fall of your
own breatheach time you drift, gently returning back to your own breath.
And if you find yourself irritated, wanting to move along, just notice
thatthat pushand imagine that you just gently release that and come
back to this very next breathand this breath.
Now I want to invite you to imagine that file cabinet before youand
remember, as you gaze at that cabinet, those photos you looked at previously.
Just let the weight of that rest on you. See if you can let yourself recall the
ways you struggled with that, and before you open the cabinet, take a minute
to breathe those struggles in and out. Ill ask you to reach forward and let your
fingertips come gently to rest on the handle of that file cabinet. Imagine that
you slowly and gently draw the file cabinet open. Let your hand rest on the
files, and let yourself know the costs that are written on the photos.
Let yourself find, in that cabinet, a photo of your client on the very last
day of her life. Gently draw the photo out. Maybe imagine the paper is fragile,
that you have to take it out with care and gentleness. Bring it to rest in your
lap, and see if you can hold it like some sad but treasured thing. Just notice
the feel of it as you cradle it and breathe. Let your eyes begin to see that client
on the last day of her life. See if you can let yourself notice the tiniest details
in her face as she sits on that last day. See if you can let yourself see, in those
eyes, all of those costs that she has paid. Let yourself see in her face someone
who can look out across the years and know all the costs that have been paid.
See if you can see in that face someone who once hoped for more or somebody
who couldnt take it home. Let yourself notice that you can only be a witness
to this; theres no way you can reach in and stop it. And breathe. Let it be as
if the cost this person paid can be breathed in and out like air, so that as you
witness her, you become saturated with those costs. And breathe.
Now I want you to imagine that you take one last look into the face of
that client, and let yourself know what it would have meant to you to have
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been an instrument to her, to make a difference to her. See if you can let
yourself feel sorry for that. Then gently, gently let that clients photo slip back
into the file cabinet, and just linger for a moment with your hand on top of
those photos, breathingand gently let the drawer slide closed, listening to the
sounds as it slides closed.
Now imagine that youre in the therapy room, and that it is some time in
the next week, and that this client is sitting across from you, as she is right now.
If its a client you dont see anymore, let it be as though she has returned. Picture
her forming up in the chair across form you. Observe how she holds herself, how
she shapes her body as she sits in the chairand breathe. Let your eyes come to
rest on her face. Is she turned away from you, toward you? What is the look on
her face? Does she look sad, happy, angry, or bored? Just let yourself notice the
details of her face: the way the hair lies on her face, her eyes, her breathing. See
if you can look into that face and recall that person on the last day of her life,
and see if you can see those costs in that facethe price that will be paid. If you
looked into that face, you could see her own fear of the course her life will follow.
Notice your longing to make a difference, to reach out to her.
Take a moment of silence. Just be a witness to this client and her struggle. Just gently be a witness to that, as if you were watching a painting or a
sunset.
Now imagine that your awareness is like a liquid, and you can be poured
into the client. Your awareness is like water, and you begin to become aware
from the inside of what she feels like. Let that awareness gently fill her body and
beingto feel that the way she shapes her body shapes your awareness. Feel it
pull and twist at you so that the shape of that clients body, the way she holds
herself, starts to shape you. Let that awareness fill you and fill you, so that you
start to feel from within her skin what its like to sit in that room. Let it fill you
and fill you right to the top of your head. See what its like to be sitting across
from that therapist. What is it like to be sitting across from him? How do you
feel toward that therapist? Will he help you? Will he hear you? Can he possibly
know what its like for you? Let yourself breathe that therapy room in and out
with your clients breath. Let yourself breathe the air she breathes.
[Pause.]
Let the words drop away, let your eyes close for just a moment. See if you
can just feel the quality of the interaction so far. Notice the pitch and pace. If
youre the therapist, notice whats tugging and pulling at you. Are you trying
to get it right? See if you can get a feel for the way the client feels, for what
words shes usingalmost as if you can hear a faint song in the background.
If youre a witness, see if you can let yourself notice the client and the therapist,
the qualities of their interaction. Like a naturalist, stop, watch, and listen.
Therapists, if youre working hard, just let go of that. If youre the client, see
218

Making Experiential Contact with Mindfulness

if you can feel what its like to be that person. Be true to the client. Fight for
her experience in the therapy room. Breathe. When youre ready, let your eyes
reopen and rejoin the therapeutic interaction. Give yourself a chance to meet
that client; give the client a chance to be met.
And once again, let yourself pause. Let the words drop away and let your
gaze fall to the floor. Just let all of that experience sort of gather around you, as
if your awareness could come to light on one aspect of the experience and then
another. Without doing anything with it, notice anything you want to do something with. Let this go and just be a witness to that experience. Let all those
pushes and pulls be more of that air you can breathe in and out. And once
again, I want you to just gently come back to the interaction. Pause for just a
moment. When youre ready, let yourself come gently back to the interaction.

Debriefing: Client
Once more, let the words drop away. Take a moment or two in the next
section of the work. To the client, see if you can give expression to what its
like to sit inside the skin of the client. Dont be nice. What did you see, what
did you hear, what did you feel? Where were the places you felt joined or not
joined? Avoid analysis and stay very close to experience. What was the experience, how did it move, what were the contours as you moved through it? Stay
with the experience.
Pause for just a second and consider what the client might hope for in the
room.

Debriefing: Therapist
Stay close to experience. What was it like to sit in the room with the
client? What were the ebb and flow and contour of that experience? Again,
avoid analysis.

Debriefing: Witnesses
Now the people who witnessed the exchange, what was it like to watch
the client-therapist interaction? Again, no analysis. Stay with experience. How
did the interaction tug at you as a witness?
219

Mindfulness for Two

Finishing Up
Let the words drop away. Take a moment, breathe, and let yourself be saturated by all of the different experiences in the interaction: the experiences of the
client, the therapist, and the witnesses. Pause and just appreciate the complexity,
the richness of those experiences. See if, for just a moment, your awareness can
just gently release those experiences. Let your awareness come to rest on your
own breath. Notice how your thoughts and experiences clamor for your attention. Return to your own breathing, to that same gentle inflow and outflow
of breath. See if you can notice that, through all of these interactions, there
remained that gentle inflow and outflow of breath, requiring nothing of you and
yet sustaining you. Kindly give your own breath a moment of appreciationa
simple thing that sustains you even when you dont have time for it.

Debriefing the Experiential Role Play


We humans are really attracted to facets of the hexaflex that we
really have nailed, and we spend less time on those facets we dont know
so well. Go back into the therapeutic relationship and look for those
facets that you dont have a good sense of. See if you can structure your
questions like What line of inquiry can take me into the facets of the
hexaflex that I dont see evidence for?
How much permission do we have as therapists to press clients,
to move where the clients want to take us? How do we get permission
to move forward? How do we check in with clients to see what theyre
willing to take up? Can you say, It matters to me what your experience
here is, and I feel like were up against something hard. Can you find a
way to really honor their answers whether they say yes or no? What are
the challenges to observing the role plays?
Whats sweet in your clients life? If you dont think theres sweetness in your clients life, what could be sweet? Do you know what might
be sweet in his life? Can you appreciate what this sweetness might be in
her life? Can you let the client show you either what is sweet or what he
might long for?

Reinduction
Let your eyes gently close. Just let your attention come gently to rest on
your own inflow and outflow of breath. See if you can notice how steadfast
220

Making Experiential Contact with Mindfulness

your breath is, how reliable. And if you find yourself becoming distracted,
just see if you can notice those distractions, maybe give them a nodyou can
come back to them later. But for now, let your attention gently, gently come
back to your own breathing. See if you can begin to notice the tiny sensations
that can be found in the inflow and outflow of each breath.
It neednt be forceful, but when you find your mind wandering, gently
carry it back to your breath.
And now imagine once again that photograph of your client and hold it in
your lap. Let yourself recollect; let yourself see that face. And breathe. Just let
your eyes linger on that face for a moment, breathing in and out. And then let
that photo dissolve, dissolve, breathing. And let yourself begin to see that client
of yours as she is right now. See if the exercises youve done will let you see just
a little more deeply into the suffering of that person. Let yourself soften to that
suffering, let yourself be penetrated by it. Notice how she holds her body, how
she holds her life; feel that tension and that narrowness that constrains her.
Breathe. And once more, imagine that your awareness can become a liquid
that is poured into the skin of your client. With kindness, gently pour your
awareness into your client. Let yourself begin to feel that trap that your client
feels herself to be in. As your awareness fills your client up, let the way she
holds her body begin to shape yours. Let the trap that she finds herself in grab
hold of your awareness and squeeze it. Let yourself wonder, Will my therapist
see me? Can anyone understand me? Know me? Just let yourself breathe that
struggle in and out.
When youre ready, open your eyes as the eyes of your client. Be true to
her. Be her voice in this room. Respect her by being true to her. When youre
ready, rejoin the conversationthe same session, the next session. Go ahead
and rejoin that conversation.
[Pause.]
Let the words drop away. Let yourself go silent. You can continue to go
along this path, but stop for just a moment to rest. See if you can bring your
awareness to your own pace. Is there urgency to it? Are you hurrying? Just let
it well up around youand breathe. When youre ready, I want you to come
back to the interaction and see if you can really bring intention and awareness
to your pacing. See if you can find a pace where you are right there with your
client. Just take a moment, take a few breaths, and notice the gentle inflow of
breath. Witnesses, see if you can just practice bringing attention to one or the
other side of the interaction. Breathe. And when youre ready, just let it be as
if you stood back up on that same trail and then took your time moving back
in the way youve been going.
[Pause.]

221

Mindfulness for Two

One more time let the words drop away, and let your eyes gently close.
Notice what its like to be that therapist, that client. If youre observing, have a
heart for both the client and the therapist.
Therapist, you have the flavor of your client now. Imagine that your
awareness could be poured into that body across from you. Imagine that your
awareness can be poured like water into the skin of the person across from
you. Let yourself take on the feel, the posture of that client.
[Participants reverse roles.]
Imagine yourself being poured across that transaction. When you open
your eyes, be yourself, the therapist, looking across at your client.
If you were the therapist, feel what its like to be the client. Was that
person hearing you at all? When you open your eyes, rejoin the workexcept
with the roles of therapist and client reversed.
[Pause.]
What is it like to sit in that aware place as a client and as a therapist?
Consider this question: If you werent in the room with that client, trying
to say the right thing, what would you like to say to her? Take a minute. Let
your attention come to rest on your own breath, and then gently, gently come
back to the interaction.
[Pause.]
One last time, let the words gently drop away. Youre not done. There
is no done. Let the whole experience gather around you. What was it like
client, therapist, witnesses? Draw your attention to your own breathing. There
it is, waiting for you. If you find your mind wandering, let it come to rest on
your own breath. Notice the way the mind wants to pull you this way and
that, to get on to the next thing. Notice then that your breath is there, waiting
for your return. Just take a moment to appreciate that sweet simple thing: your
own breath moving in and out of your body. This very breath.
And now open your eyes and take a few minutes here to stay close to the
experience. What kinds of things did you notice? Not analysis, but what was
the experience like? What was the transition like? If you were observing, what
did you see?

Debriefing the Experiential Role Play and Mindful


Case Conceptualization
All of the debriefing instructions described for the Sweet Spot and
the Client Descending should be applied to this exercise. The exercise

222

Making Experiential Contact with Mindfulness

provides a very rich set of interactions. Linger over them. Your inclination is likely to be to absolutely launch into case conceptualization.
Notice that eagerness to move to the conceptual. Cause your little group
to pause until you can sit with the urgency. You can do this, but it will
require you to bring your careful attention to bear on the task in a way
that is very, very different from our usual shift into the conceptual.
In addition to the debriefing suggested in the previous exercises,
consider adding these small additional instructions:
1. Designate someone in your group to ring the bell, as it were,
to call the small group to a mindful moment during the
case conceptualization. Encourage anyone in the group to
request such a moment if they feel the process is racing away.
It will be good practice for the group to respect the process
for others and to notice their own drive to action.
2. Have everyone in your small group bring their hexaflex
worksheets into their lap and let their eyes travel across the
sheets. Remain silent and allow your eyes to travel across
the sheet without writing anything. If you begin to think of
things to write, gently let those go, and look around at your
little group and let yourself soak in the magnitude of the
human task we have all adopted.
3. Case conceptualization of the therapist: Work through a case
conceptualization of the therapist (as described in chapter
7). Be sure to walk all the way around the hexaflex. Take
some mindful moments in this process. Just stop. Please.
4. Case conceptualization of the client: Work through a case
conceptualization of the client (as described in chapter 7).
Be sure to walk all the way around the hexaflex. Take some
mindful moments in this process. Just stop. Please. We have
time enough.

223

Epilogue

Slowing Down

One of the central arguments of this book, and I think of ACT generally,
is that all of uswhether client or therapistexperience similar problems in living. These problems vary from each to each in degree but not
in kind. This egalitarianism of dysfunction, of course, extends to authors
too. So now its my turn to wander from the present moment and worry
about the unknowable future.
How will this book be received?
This book was born from science, but I didnt write it primarily for
scientists. There are a thousand places in the preceding pages where I
might have unpacked the empirical and theoretical justification for my
assertions. Had I done that, though, most clinicians would have stopped
reading before finishing the first chapter.
I believe there is relevant empirical evidence, theory, or both for the
work Ive described herein. I have spent a lot of time in other contexts
making the scientific argument for all Ive claimed in these pages, and
Ill continue to do so. But setting forth an exhaustive, scientific account
of the whys and wherefores of mindfulness for two wasnt the purpose of
this book. Instead, I wanted to offer you something in the way of a very
practical experience that could shape the conversations you have with
your clients.
Because I took for granted a number of theoretical and empirical
matters, I know Ill draw criticism for this book. Some scientists will
cluck their tongues. I can live with that. I never intended this to be an
endpoint of a scientific analysis. Rather my vision was for it to be part of
an iterative process that moves between the clinic and the lab, between

Mindfulness for Two

basic and applied theory, between the highly theoretical and the wholly
practical. My hope was to speak to clinicians, and, to a somewhat lesser
extent, to set an empirical agenda for scientists who can see both the
science from which this work comes and the human need it seeks to
fulfill.
We have time enough to sort these matters out, though it often
doesnt seem so. Our savanna minds didnt keep us alive by idling away
the hours. But you took time for this odd book. Perhaps you were looking
for a significant, hard-to-define something more in your own work. Its my
hope that taking this time will help you to make time for yourself and for
the people you serve.
What would it mean if we slowed just a bit? What would it mean to
stop long enough to recognize our own face in the mirror one morning?
What would it mean to look deeply into those eyes? What does that
person we see there need? Do we have time to recognize that person?
To listen? To hear our own hearts? What small gift could you make to
yourself this day? What kindness would you offer?
This book is a small gift Ive offered to myself. Its a place where Ive
let the years that have welled up around me spill out. Ive attempted to
give voice to the influences of hundreds of teachers, clients, students, and
friends of this work worldwide. This book is a place where Ive allowed
myself to speak in my own voice. I hope that all of you who have contributed will hear a bit of your voice echoed in mine. I hope that those of
you who are just now joining me will find things in these pages that serve
both you and the clients you serve. Well need to slow down in order to
really answer these questions. Kindness is a simple thing. And sometimes
a return to simple things can help us.
At times we feel the need to go back
to plain things. To stones, earth,
grass, wind. To things we have known
a long time, to what we knew
when what filled the hours was dirt
and a few sticks, a pile of leaves
or some thin, white bones
from a long-dead bird.
The huge rock near the creek
was not too hard to lie on then

226

Slowing Down

and the sun on bare skin felt warm.


We did not feel the press of time
as we do now. The world seemed firm
and real, and life was slow, and long, and good.
Carolyn Elkins, What We Knew (2002, 23)

227

Appendix A

Using the Mindfulness for Two


DVD-ROM

Bound into the back of this book, youll find a DVD-ROM with all sorts
of interesting things you can use to support your experience with the
book. Although the disc contains video, it isnt a DVD that you can play
in your DVD player and watch on your television set. In order to use the
disc, youll need a personal computer.

VIDEO
There are seven video segments on the disc. You can see the Sweet Spot
and Client Descending exercises, and you can practice case conceptualization on the six remaining experiential role plays. In particular, I offer
a case conceptualization of Emily and Kate: Session 2 in chapter 7.
The worksheets with my notes appear on the disc as Emily and Kate 2
HDFEI.pdf.
These segments were filmed in Denver, Colorado, in April 2008.
The individuals who appear in these videos as clients adopted invented
clinical personae for illustrative purposes, but I would resist calling what
you see in these segments acting. While the clients assumed some
details that would lend structure to the interviews, I think youll agree,
after you watch the videos, that something essentially human and undeniably real emerges. All of the participants, therapists and clients alike,

Mindfulness for Two

had recently completed a three-day training with me on the material


featured in this book. Though the personae they adopt for the videos are
invented, with their permission we used the real names of the participants to identify them in these segments.
In order to view these videos, you need to use QuickTime player,
which is available free of charge for both the Windows and Apple platforms at www.apple.com.
The segments are named according to the individuals they feature:

Emily and Kate: Session 1 (Sweet Spot Exercise)


Ellen and Matt (Client Descending Exercise)
Ragnar and Brandon (an experiential role play)
Emily and Kate: Session 2 (an experiential role play)
Bennett and Cari (an experiential role play)
Joanne and Lisa (an experiential role play)
Kelly and Cari (an experiential role play)
AUDIO
Youll find three audio clips in MP3 format that include my voice doing
real-time inductions to the three mindfulness exercises in chapter 8:
Sweet Spot, the Client Descending, and the Experiential Role Play.
Depending on how your system is configured, you should be able to move
these files into any major audio software and, from there, onto a portable
music player or a CD for playback.

PDF WORKSHEETS AND DOCUMENTS


The worksheets and figures in the book also appear on the disc in PDF
format. Feel free to print them and use them as you please in your clinical and educational work. To view and print these documents, youll
need either Adobe Acrobat or Adobe Reader. Adobe Reader is available
free of charge at www.adobe.com.

230

Appendix B

The Valued Living Questionnaire


(Version 1)

The Valued Living Questionnaire that appears in chapter 7 was refined


from an earlier version especially for use with the HFDEI as its presented
in this volume. The original version has been used in a variety of research
projects and may be of interest for some researchers and practitioners. It
is reproduced below, and there is a reproducible PDF version available on
the DVD-ROM.

Mindfulness for Two

Valued Living Questionnaire


Below are areas of life that are valued by some people. We are concerned
with your quality of life in each of these areas. One aspect of quality of
life involves the importance one puts on different areas of living. Rate the
importance of each area (by circling a number) on a scale of 1 to 10. 1
means that area is not at all important. 10 means that area is very important. Not everyone will value all of these areas, or value all areas the same.
Rate each area according to your own personal sense of importance.
Area

not at all
important

1. Family (other than


marriage or parenting)

1 2 3 4 5 6 7 8 9 10

2. Marriage/couples/
intimate relations

1 2 3 4 5 6 7 8 9 10

3. Parenting

1 2 3 4 5 6 7 8 9 10

4. Friends/social life

1 2 3 4 5 6 7 8 9 10

5. Work

1 2 3 4 5 6 7 8 9 10

6. Education/training

1 2 3 4 5 6 7 8 9 10

7. Recreation/fun

1 2 3 4 5 6 7 8 9 10

8. Spirituality

1 2 3 4 5 6 7 8 9 10

9. Citizenship/community life

1 2 3 4 5 6 7 8 9 10

10. Physical self-care


(diet, exercise, sleep)

1 2 3 4 5 6 7 8 9 10

232

extremely
important

The Valued Living Questionnaire

In this section, we would like you to give a rating of how consistent


your actions have been with each of your values. We are not asking about
your ideal in each area. We are also not asking what others think of you.
Everyone does better in some areas than others. People also do better at
some times than at others. We want to know how you think you have
been doing during the past week. Rate each area (by circling a number)
on a scale of 1 to 10. 1 means that your actions have been completely
inconsistent with your value. 10 means that your actions have been completely consistent with your value.
During the past week
Area

not at all
consistent
my value

completely
consistent with
my value

1. Family (other than


marriage or parenting)

10

2. Marriage/couples/
intimate relations

10

3. Parenting

10

4. Friends/social life

10

5. Work

10

6. Education/training

10

7. Recreation/fun

10

8. Spirituality

10

9. Citizenship/community
life

10

10. Physical self-care


(diet, exercise, sleep)

10

233

Recommended Reading

What a dangerous section to include! This alone could take up the entire
page count. Id better keep it brief.

ON ACT
ACT literature for clinicians is growing fast. To date, much of it has
been published by New Harbinger, whose website is a good place to look
for other book and video titles: www.newharbinger.com. New Harbinger
also publishes a range of client-focused ACT books that can be used for
self-help or integrated into therapy, most notably Get Out of Your Mind
and Into Your Life, by Steve Hayes with Spencer Smith.
The major book that develops the theoretical foundations of ACT is
Acceptance and Commitment Therapy, by Steve Hayes, Kirk Strosahl, and
Kelly Wilson (Guilford Press, 1999). This title is currently under revision; the new edition will be available from Guilford in 2009. Arguably
the other foundational title for ACT is Relational Frame Theory: A PostSkinnerian Account of Human Language and Cognition, by Steve Hayes,
Dermott Barnes-Holmes, and Bryan Roche (Springer, 2001). While dense
and technical, these books offer unparalleled access to the theoretical
mechanics that make ACT what it is.

Mindfulness for Two

ON MINDFULNESS
There are quite simply too many books on the subject of mindfulness,
both within and without the great spiritual traditions, for me to mention.
To recommend some may seem to slight others through negligence, which
surely wouldnt be my intention. I have tremendous respect and affection for Jon Kabat-Zinn and believe that his books are required reading
for those interested in a clinical application of simple, conscious awareness to the present moment. In this area, however, I recommend that
you let your curiosity be your guide. I would also recommend the reader
look at the work of Mark Williams, Zindel Segal, and John Teasdale
on mindfulness-based cognitive therapy (MBCT). Though these books
all come at the work from a very different perspective, we are certainly
fellow travelers.

OTHER BEAUTIFUL BOOKS REFERRED TO


IN THIS TEXT, AND UNMENTIONED BUT
IMPORTANT INFLUENCES
Victor Frankls Mans Search for Meaning, in case you hadnt gathered as
much, has meant a very great deal to me. A number of editions are in
print, notably from Beacon Press. Carl Rogerss On Becoming a Person
seems essential. The poems of T. S. Eliot are good for lifetimes of reflection. His collected poems and plays are available in a nice hardcover
from Harcourt (1952). Also, in the realm of poetry, I recommend Carolyn
Elkinss Daedalus Rising from Emerys (2002). The reference I made to
Camus An Absurd Reasoning can be further explored in The Myth of
Sisyphus and Other Essays, which is available from Vintage International
in the 1991 edition. My relationship with Camus essays is long and deep.
I got my first copy of the essays thirty-eight years ago from my brother
Randy. My love for these essays has only grown since that time.
I referred to Sebastian Moores Let This Mind Be in You: The Quest
for Identity Through Oedipus to Christ (Winston Press, 1985), which is
a wonderful book. Moore is a bit psychodynamic for my taste, but the
sensitivities are exquisite. Also in the area of spiritual writing, though I
didnt reference it specifically in the book, Im very taken with Dao De
Jing: A Philosophical Translation, by Roger Ames, David Hall, and Lao Zi

236

Recommended Reading

(Ballantine, 2003). Ernest Kurtz and Katherine Ketcham and their book
The Spirituality of Imperfection: Storytelling and the Search for Meaning
(Bantam, 1993) are a principal source of my persistent interest in sitting
inside significant questions. The book is nominally about spirituality in
Alcoholics Anonymous, but really the stories are marvelously universal.
I cannot overemphasize the importance of behavior analytic writing
and thinking on the development of this work. Do yourself a favor and
read what B. F. Skinner actually wrote rather than relying on secondhand reports by people who never really did their homework. I heartily
recommend Skinners essays in volumes such as Cumulative Record, first
published in 1959, or Contingencies of Reinforcement, published in 1969.
Neither is still in print, though used copies can be found online. If you
want to get a taste of the really odd edges of behavior analysis that captured my attention, please read some Willard Day. Sadly, Willard died
fairly young and talked more than he wrote. However, my first teacher of
behavior analysis, Sam Leigland, compiled a volume of Willards canonical papers in a volume called Radical Behaviorism, which can be purchased from New Harbinger under the Context Press imprint. With the
Skinner volumes and especially with Willards contribution, youll begin
to get a sense of the incredibly broad range of interests that can be found
within the behavior analysis tradition. Narrow indeed!

RECOMMENDED BROWSING
The Association for Contextual Behavioral Science (ACBS) is a central
point for all things ACT, and it serves as a hub for the functional contextual cognitive behavioral sciences. The website, www.contextualpsychology.org, features articles and information, a calendar of training events,
and the schedules of the ACT Summer Institutes and international conferences. Membership in ACBS is required to access much of the information on the site, but, in keeping with ACTs values orientation, ACBS
annual dues are values based. You set your annual dues according to how
much value you place on membership. As little as $1 will get you into this
exciting and supportive community.

237

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243

Kelly G. Wilson, Ph.D., is associate professor of psychology at the


University of Mississippi. He is a central figure in acceptance and commitment therapy (ACT), and was one of the authors of the landmark
Acceptance and Commitment Therapy. (Guilford Press, first edition 1999,
second edition 2009). Wilson is among the most sought-after ACT trainers. His popular experiential workshops touch thousands of clinicians
and students each year. www.onelifellc.com
Troy DuFrene is a writer specializing in topics in psychology. He is
c oauthor of Coping with OCD (New Harbinger, 2008) and, with Kelly
Wilson, of Things Might Go Terribly, Horribly Wrong (New Harbinger,
2010). DuFrene lives and works in the San Francisco Bay Area. www
.troydufrene.com

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