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“This intensely practical book offers

a cutting-edge evidence-based
framework for mental health pro-
fessionals seeking to more effect-
ively address the myriad interper-
sonal problems that individuals
seeking psychotherapy face in their
daily lives. It is the first book of its
type to bridge the more cognitive
notions of schemas with newer
mindfulness and acceptance-based
behavior therapies such as accept-
ance and commitment therapy. The
authors know both worlds intim-
ately, and offer a straightforward
approach that gets to the heart of
patterns of unhelpful interpersonal
behavior that ultimately damage
significant social bonds. The book is
full of practical exercises, work-
sheets, and even a full-length pro-
tocol outlining its use in either an
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individual or group therapy format.


This book is a must-read for any
mental health practitioner who
takes seriously the significant social
and interpersonal problems faced
by those they serve.”
—John P. Forsyth, PhD,
professor of psychology
at University at Albany,
SUNY, and director of
its anxiety disorders re-
search program

“Acceptance and Commitment


Therapy for Interpersonal Prob-
lems is a user-friendly guide to
helping your clients employ ACT to
manage the pain and suffering
caused by unhelpful schemas that
contribute to the relationship dis-
tress that often accompanies the
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personal disorders they bring to


their sessions with you. This book
will guide you through a step-by-
step process for helping your clients
accept schema-related pain in the
service of values-based interperson-
al behavior. Highly recommended.”
—Richard Blonna, EdD,
author of Stress Less,
Live More

“Interpersonal difficulties are a


common focus of clinical work,
either as a primary presenting
problem or one that further com-
plicates other issues that clients
bring with them to therapy. This
book skillfully integrates schema
theory with acceptance and com-
mitment therapy. Matthew McKay,
Avigail Lev, and Michelle Skeen
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guide the reader through a system-


atic program emphasizing mindful-
ness and compassionate acceptance
of thoughts, feelings, and urges that
typically result in interpersonal dif-
ficulties, along with the clarification
of personal values to inform altern-
ative ways of relating to others.
Numerous handouts and forms
throughout, as well as an appendix
with a session-by-session protocol,
provide an easy-to-follow set of
empirically-supported guidelines.
This book should be a welcome ad-
dition to the library of all mental
health professionals who struggle in
working with clients who find their
relationships with loved ones,
friends, and coworkers more often a
source of psychological pain than
fulfillment.”
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—Robert D. Zettle, PhD,


professor of psychology
at Wichita State
University and the au-
thor of ACT for
Depression

“Mental health professionals inter-


ested in new horizons in evidence-
based treatments will find this book
to be a valuable first step in the dir-
ection of integrating acceptance and
commitment therapy into their
work. This book offers a unique
journey through the ACT material
by integrating the vernacular of tra-
ditional cognitive behavior therapy.
The authors dare ACT therapists to
broaden the scope of their concep-
tualizations while challenging CBT
therapists to apply mindfulness and
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acceptance to their toolbox of


interventions.”
—D.J. Moran, PhD, BCBA-
D, founder of Pickslyde
Consulting and the
MidAmerican Psycholo-
gical Institute

“While chronic interpersonal prob-


lems are often the most difficult to
address clinically, this book
provides new hope for the clinician.
It is simple, practical, sound, and
evidence-based.”
—Kirk Strosahl, PhD, co-
founder of acceptance
and commitment ther-
apy and coauthor of The
Mindfulness and Ac-
ceptance Workbook for
Depression and Brief
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Interventions for Radic-


al Change

“Over the years, different therapy


approaches have attempted to help
clients struggling with interperson-
al problems. Despite showing some
benefits, none of these approaches
made a significant difference in
these clients’ lives. Finally, ACT for
Interpersonal Disorders offers
readers an alternative that is not
only innovative, but also based in
research. This book sets a gold
standard for how to integrate ACT
and schema therapy and shows us
step by step how to make real
changes in the lives of clients strug-
gling with their relationship to their
own pain and relationships with the
people they care about.”
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—Patricia Zurita Ona,


PsyD, clinical supervisor
at the Berkeley Cognit-
ive Behavioral Therapy
Clinic and the Wright
Institute’s behavioral
medicine training
program

“McKay, Lev, and Skeen present a


successful, innovative combination
of ACT and a schema-based ap-
proach to help clients with interper-
sonal relationship problems gain
more behavioral flexibility and
move beyond inflexible patterns of
relating. Rather than changing dys-
functional schemas or core beliefs,
the authors teach readers in clear,
practical steps how to help clients
alter the way they relate to their
thoughts so that they can choose
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different responses based on their


chosen values. The book is based on
long-term clinical and research ex-
perience that shows how clients
gain greater psychological flexibility
through building acceptance and
defusing from unhelpful thoughts,
emotions, and beliefs—including
schemas. With its many worksheets
and exercises, as well as a session-
by-session treatment outline, this
book is a great resource for any
therapist who wants to help clients
develop less conflict-filled, richer,
and more fulfilling life.”
—Georg Eifert, PhD, pro-
fessor emeritus of psy-
chology at Chapman
University
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“Relying on a storytelling clinical


voice, the authors articulate an in-
novative approach to applying ACT
technology to interpersonal prob-
lems using the language of schemas
(e.g., abandonment, failure) as a
heuristic to identify historic
thoughts, feelings, and action urges
that are sources of pain and un-
likely to go away. The book de-
scribes a step-by-step treatment ap-
proach wherein the clients learn to
recognize old moves to avoid the
emotional pain associated with
these schemas and discover how to
stop these behaviors that create un-
necessary interpersonal suffering. It
includes clear descriptions of inter-
ventions, with samples of therapist-
client dialogue and handouts to use
with clients. The book is based on a
small randomized controlled trial in
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a group setting and indeed, it in-


cludes that protocol in one of the
appendices; however, the material
presented in this book could easily
be utilized in individual and couples
therapy, as well.”
—Jacqueline Pistorello,
PhD, coauthor of Find-
ing Life Beyond Trauma
Publisher’s Note
This publication is designed to provide ac-
curate and authoritative information in re-
gard to the subject matter covered. It is sold
with the understanding that the publisher is
not engaged in rendering psychological, fin-
ancial, 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 © 2012 by Matthew McKay, Avi-
gail Lev, and Michelle Skeen
New Harbinger Publications, Inc.
5674 Shattuck Avenue
Oakland, CA 94609
www.newharbinger.com
Cover design by Amy Shoup; Text design by
Michele Waters-Kermes; Acquired by Cath-
arine Meyers;
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Edited by Jasmine Star


All Rights Reserved
_________________________________
Library of Congress Cataloging-in-Publica-
tion Data
McKay, Matthew.
Acceptance and commitment therapy for in-
terpersonal problems : using mindfulness,
acceptance, and schema awareness to change
interpersonal behaviors / Matthew McKay,
Avigail Lev, and Michelle Skeen.
p. cm.
Summary: “Acceptance and Commitment
Therapy for Interpersonal Problems offers a
complete professional protocol for treating
clients who suffer from a variety of interper-
sonal issues, including tendencies toward
blame, withdrawal, anger, contempt, defens-
iveness, and distrust. Based in acceptance
and commitment therapy (ACT) and schema
therapy, this approach helps clients
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understand and move past their interperson-


al disruptions and difficulties”-- Provided by
publisher.
Includes bibliographical references and
index.
ISBN 978-1-60882-289-8 (hardback) --
ISBN 978-1-60882-290-4 (pdf e-book) --
ISBN 978-1-60882-291-1 (epub)
1. Interpersonal psychotherapy. 2. Interper-
sonal relations. 3. Acceptance and commit-
ment therapy. I. Lev, Avigail. II. Skeen,
Michelle. III. Title.
RC489.I55M35 2012
616.89’14--dc23
2012003631
Contents
Foreword
INTRODUCTION
CHAPTER 1: THE CHALLENGE OF
TREATING INTERPERSONAL
PROBLEMS
CHAPTER 2: INTRODUCING
SCHEMAS
CHAPTER 3: UNDERSTANDING
SCHEMA COPING BEHAVIORS
CHAPTER 4: CULTIVATING
CREATIVE HOPELESSNESS AND
DEVELOPING MINDFULNESS
SKILLS
CHAPTER 5: CLARIFYING VALUES
AND COMMITTING TO VALUES-
BASED ACTION
CHAPTER 6: DEFUSING FROM
THOUGHTS AND DEVELOPING THE
OBSERVER-SELF PERSPECTIVE
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CHAPTER 7: CONDUCTING
EXPOSURE WITH DEFUSION
CHAPTER 8: WORKING WITH SIX
KEY PROCESSES
Appendix A: Schema Questionnaire
Appendix B: Research Outcomes
Appendix C: Group Protocol (Written with
Koke Saavedra)
References
Foreword

This is the first book of which I’m aware


that combines ideas from schema-focused
therapy with methods from acceptance and
commitment therapy (ACT). These two treat-
ment approaches come from different wings
of the cognitive behavioral community,
which could suggest that they will be in con-
flict. In the hands of these authors, that nev-
er happens.
This book approaches schemas simply as
well-ingrained patterns of thought. There is
nothing in this idea that violates ACT.
Schemas imply a kind of functional theme,
and the authors focus on ten patterns of par-
ticular importance to interpersonal prob-
lems: abandonment, mistrust, deprivation,
defectiveness, alienation, incompetence, fail-
ure, entitlement, subjugation, and hypercrit-
icalness. Chunking patterns of thinking into
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larger units and themes in this way can make


it somewhat easier for the clinician to detect
larger patterns and see the possible functions
for more fine-grained thoughts. It can help
the client and clinician alike see the forest
and not just the individual trees.
Building on the identification of schemas,
the tested protocol presented here brings
ACT sensibilities to how schemas can be ad-
dressed effectively. That is, schemas, once
identified, are addressed largely through
ACT methods. The authors make that task
easy by thinking about schemas in a func-
tional sense. Just as in traditional ACT,
which holds that fusion with thoughts leads
fairly directly to experiential avoidance, in
the schema-focused perspective described in
this book, coping with schemas leads fairly
directly to avoidant forms of adjustment. The
functions of schema coping behaviors are to
escape from or avoid the emotional pain that
is connected to a particular pattern of
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thinking. That helps turn schemas into


themes to be used to detect unhelpful pat-
terns of avoidance and their history. It’s a
useful idea that is put to good use in this
book.
One reason to take a more schema-fo-
cused approach in the domain of interper-
sonal problems is that such problems
present themselves in a bewildering variety
of forms. It is very easy to get caught up in
content—in the details of the interpersonal
stories and difficulties that make up the psy-
chological aspect of the social world. Every-
one has relationship difficulties from time to
time, but this book is focused on recurring
difficulties in relationships based on chronic-
ally dysfunctional styles of interacting. When
dealing with problems of that kind, the lar-
ger patterns are more important than the de-
tails of a given instance.
Many years ago, language researchers de-
termined that human language has a limited
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set of analytic dimensions; you could sum-


marize the myriad evaluative themes into
just three polar dimensions (good/bad,
strong/weak, and fast/slow). Schemas can
help in much the same way. If you can avoid
reifying them, or turning them into causes,
schemas can help focus clients and clinicians
alike on a small set of themes to apply to the
many details. The act of looking for larger
patterns helps clients take a more defused
and mindful look at their own behavior, and
it can empower the search for ways to create
new forms of adjustment. It helps clients
step back and ask “What am I up to here?”
and “What are the larger patterns of rela-
tionship that I am building in this moment?”
That step—of backing up and looking for lar-
ger patterns—is a powerful ally of change. It
is not by accident that this book uses ACT
methods in service of this process, because
the process is entirely ACT consistent.
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The protocol in this book constantly dir-


ects the clinician’s attention toward the func-
tion of thought and emotion, and the con-
struction of more effective behavioral pat-
terns. It is very much to the credit of the au-
thors that the protocol itself has been tested
so we can say with some confidence that it
can be of help in working with interpersonal
problems. Detailed descriptions of interven-
tions are provided, and scripts help readers
envision when they might be used.
There are a limited number of ap-
proaches available for interpersonal prob-
lems. It is still early, but I believe this book
adds another method to that list of ap-
proaches. Given how pervasive and destruct-
ive interpersonal problems can be, it has not
arrived a moment too soon.
—Steven C. Hayes Foundation Professor,
University of Nevada
Introduction

Clients present with interpersonal prob-


lems that often occur across multiple rela-
tionships and life domains (friends, work,
family, partner, and so on). Pervasive inter-
personal problems can thus reach a level that
could be seen as an interpersonal disorder,
contributing to failed relationships, social
isolation, depression, and work dysfunction.
Clients struggling with interpersonal
problems are frequent visitors to therapists’
offices. At the Berkeley Cognitive Behavioral
Therapy Clinic, for example, more than 50
percent of our intakes identify significant re-
curring interpersonal difficulties. The major-
ity of clients presenting with depression,
trauma, anxiety, and Axis II disorders report
interpersonal problems in more than one im-
portant relationship. Colleagues across the
country report similar data.
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Clearly, interpersonal problems are per-


vasive in the population seeking psychother-
apy. Interpersonal problems destroy rela-
tionships and trigger extraordinary suffering,
both for those affected and for those to
whom they relate. Yet for all the pain these
problems create, few systems of psychother-
apy directly target the interpersonal behavior
that drives the problem, and there is little re-
search addressing what treatments effect-
ively change disordered interpersonal func-
tioning (this is discussed in chapter 1).
Therefore, the purpose of this book is to offer
a treatment that targets relationship-dam-
aging behavior and also has some empirical
support (see chapter 1 and appendix B for in-
formation on a randomized controlled trial
of this therapy in a group setting).
Given that you are reading this book, you
probably have clients who struggle interper-
sonally and repeatedly engage in damaging
responses to relational stress. You may also
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have clients whose primary concern is anxi-


ety, depression, or trauma but who have a
history of broken relationships. Among these
clients, you may have found that treatment
targeting only the emotional problems
doesn’t help them reach high levels of well-
being. The approach outlined in this book—a
schema formulation with mindfulness- and
acceptance-based interventions—may
provide you new tools to effectively treat
these interpersonal problems.
In chapter 1, we briefly discuss current
treatments for interpersonal problems, re-
viewing their effectiveness and shortcomings
and explaining why we believe the novel
combination of ACT and schema theory is a
more advantageous approach. In chapters 2
and 3, we outline how to begin this approach
by introducing clients to the concepts of
schemas and schema coping behaviors and
helping them identify their schemas, trig-
gers, and problematic coping behaviors.
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Clients also assess how these have impacted


their lives and relationships. Chapters 4
through 7 focus on ACT processes: cultivat-
ing creative hopelessness, developing mind-
fulness skills, clarifying values, committing
to values-based behavior, cognitive defusion,
developing the observer-self perspective, and
emotion exposure. The processes and ap-
proaches in these chapters are employed to
help clients identify how they would rather
conduct themselves in relationships and to
provide motivation for undertaking the chal-
lenging work of changing long-standing pat-
terns of behavior. In chapter 8, we discuss
common issues that arise when conducting
this therapy and provide suggestions on how
to deal with those issues.
The book also contains three appendices.
Appendix A is an example of the type of
schema questionnaire you might administer
before treatment to help identify clients’ key
schemas. (We recommend the Young
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Schema Questionnaire, which you can pur-


chase at www.schematherapy.com). Note
that Appendix B outlines the results of re-
search on the effectiveness of the approach
used in this book. Appendix C provides a
detailed, session-by-session protocol for con-
ducting ACT for interpersonal problems in a
group setting. This group protocol is adapted
from the protocol used in the study summar-
ized in appendix B.
You’ll note that there are some differ-
ences in the order in which various tech-
niques are presented in the main text versus
the group protocol in appendix C. In ap-
pendix C the organization is strictly chrono-
logical, whereas in the main text, topics are
organized more thematically. This thematic
organization allows us to present similar
techniques and concepts together for clar-
ity’s sake. In practice, you might use tech-
niques from several of the chapters in any
given session in response to what’s going on
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in the room. For this reason, we recommend


that you read through the entire book—or at
least through chapter 8—before utilizing this
approach with clients.
Note that we’ve designed appendix C to
be a stand-alone guide to treatment. In the-
ory, you could photocopy this section of the
book and use it as your sole reference when
conducting group therapy. However, we re-
commend that you first read chapters 1
through 8 in their entirety so you’ll have a
deeper understanding of the approach and
the theory behind it. This will allow you to
offer group therapy more flexibly, tailoring it
to the needs of group members or situations
that arise in session.
Feel free to photocopy the handouts and
worksheets in this book for use in your prac-
tice. However, do note that these materials
are protected by copyright, so please seek
permission to use them in published materi-
al. The exception is the questionnaire in
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appendix A. It is provided solely as an ex-


ample. If you wish to use a similar question-
naire in your practice, please visit schema-
therapy.com, where you can purchase the
most current version of Jeffrey Young’s
questionnaire for research or clinical use.
Chapter 1
The Challenge of Treating Interpersonal
Problems

The currently available treatments for in-


terpersonal problems are largely inadequate.
They either fail to target and change the mal-
adaptive coping behavior, fail to address the
underlying (transdiagnostic) causes of inter-
personal problems, or fail to provide tech-
niques for tolerating interpersonal distress.
A more effective treatment is needed. This
book offers a new treatment for chronic in-
terpersonal problems, one that both targets
key components of the problem and has re-
search support.
Acceptance and commitment therapy
(ACT) has significant empirical support for
effectiveness with emotional disorders
(Eifert & Forsyth, 2005; Saavedra, 2008;
Zettle, 2007) and multiple psychological and
behavioral problems (Hayes & Smith, 2005).
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Now, for the first time, ACT has been com-


bined with a schema therapy formulation
(Young, Klosko, & Weishaar, 2003) in an ap-
proach that has been successfully applied to
interpersonal problems. We will briefly re-
view the research evidence for its effective-
ness later in this chapter and discuss it more
fully in appendix B. For now we’ll simply say
that the outcome data is promising.
Defining Interpersonal Problems
The term “interpersonal problems” refers to
recurring difficulties that clients have in rela-
tionships due to specific maladaptive re-
sponses and coping behaviors that result in a
dysfunctional interactive style. These re-
sponses and behaviors, learned in childhood,
may include withdrawing, blaming, clinging,
attacking, or surrendering. They may have
served an adaptive function at some point in
life, but in adult relationships they tend to be
problematic. For example, it may have been
adaptive for a child to avoid an angry parent,
surrender to a domineering parent, or with-
draw from a detached parent, but continuing
to use these coping behaviors in current rela-
tionships leads to further pain and suffering.
People often learn these coping behaviors
by watching their parents and other family
members deal with pain. They may have had
role models who got angry and went on the
attack when they were hurt, manipulated
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others to meet their own needs, or became


overly compliant in order to avoid
abandonment.
Not all coping strategies are learned
through modeling. When people get
triggered in relationships, they may stumble
on a response that somehow gives them a
little temporary relief and then stick with
that, doing it again and again in similar situ-
ations. These coping behaviors produce
short-term relief in the moment, but in the
long run they damage relationships. Interac-
tions stop feeling good, and after a while oth-
ers tend to harden or withdraw. This pro-
cess—trading short-term relief for long-term
interpersonal difficulties—is the source of re-
curring interpersonal problems.
Three Aspects of Maladaptive Coping
Behaviors
The patterns of maladaptive coping behavior
that arise as a result of efforts to manage in-
terpersonal needs and stressors typically
have three key aspects:

▪ They are inflexible.

▪ They are based on pathogenic be-


liefs (schemas) about self and oth-
ers in relationships.

▪ They are driven by experiential


avoidance.

Inflexible
Patterns of maladaptive coping behaviors
in relationships are inflexible because they
were formed during early childhood experi-
ences and continue to be reinforced in adult
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life (Levenson, 1995; Sullivan, 1955/2003).


They tend to be inflexible and pervasive re-
gardless of negative consequences and also
tend to create a self-fulfilling prophecy. They
aren’t altered by negative outcomes because
they are effective, temporarily, at allaying
anxiety and pain through negative
reinforcement.

Based on Pathogenic Beliefs


Jeffrey Young (1999) defines schemas as
deeply held cognitive structures and core be-
liefs about oneself and others, including par-
ticular themes and expectations about inter-
personal relationships. Schemas are deeply
ingrained because they aid in understanding
and organizing one’s world and one’s rela-
tionships. They create a sense of predictabil-
ity and safety. Further, it has been said “early
maladaptive schemas are…at the core of per-
sonality pathology and psychological
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distress, in particular personality disorders


and chronic interpersonal difficulties”
(Nordahl, Holthe, & Haugum, 2005, p. 142).
People’s pathogenic beliefs and expecta-
tions in relationships compel them to contin-
ue to use the same schema-avoidant
strategies (E. Cohen, 2002; Flasher, 2000;
Levenson, 2010; Safran & Segal, 1996). For
example, people with an abandonment and
instability schema have an expectation that
they will ultimately be abandoned in rela-
tionships. This bias leads to distortions and
selective attention toward environmental
cues of perceived abandonment. When an in-
dividual’s schema gets triggered, it elicits
particular thoughts, feelings, sensations, and
behaviors that are connected to the schema.
(In this book, we’ll use the term “schema
coping behaviors” (SCBs) to refer to prob-
lematic reactions that occur when schemas
are activated.) People may defend against
abandonment schemas through excessive
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autonomy, disconnecting, clinging, or with-


drawing. These coping behaviors are at-
tempts to escape from or suppress the emo-
tional pain connected to the schema. Schem-
as and attempts to avoid the pain connected
to them drive patterns of maladaptive inter-
personal behavior.

Driven by Experiential Avoidance


Experiential avoidance has been defined
as attempts to avoid distressing internal ex-
periences, including thoughts, feelings,
memories, sensations, and other private
events (Hayes, Strosahl, & Wilson, 1999).
Experiential avoidance occurs when people
are unwilling to experience such private
events and therefore attempt to escape or
control these experiences, even if doing so
creates more harm in the long run (Hayes &
Gifford, 1997). Control strategies may work
in the external environment; for example, if
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you’re thirsty you can get some water.


However, efforts to control internal experi-
ences are often unsuccessful and can result
in maladaptive behavior. A wide range of re-
search indicates that many forms of psycho-
pathology can be conceptualized as malad-
aptive strategies aimed at avoiding or elimin-
ating particular thoughts, memories, emo-
tions, or other distressing internal experi-
ences (Chawla & Ostafin, 2007; Gamez,
2009; Hayes, Wilson, Gifford, Follette, &
Strosahl, 1996). Therefore, targeting experi-
ential avoidance strategies in relationships
should be a fundamental component in the
treatment of interpersonal problems.
Criteria for Treating Interpersonal Problems
Given the understanding of interpersonal
problems outlined above, treatment must
target and change maladaptive coping pat-
terns. To do so effectively it must address all
three aspects of these behaviors:

▪ To address and improve behavioral


flexibility, it should encourage a
broader repertoire of behavioral
responses and help clients develop
this repertoire. Such flexibility
must be based on outcomes and
consequences and include an as-
sessment of the workability of new
and old behaviors.

▪ It must address schemas and how


they influence clients’ interperson-
al behaviors.
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▪ To target avoidance strategies, it


should provide motivation and
methods for tolerating the schema-
driven emotional pain that spawns
avoidant behaviors.
Current Treatments
Currently, several different treatment ap-
proaches are commonly used for interper-
sonal problems:

▪ Interpersonal psychotherapy:
a time-limited form of psychother-
apy, originally developed for the
treatment of depression, that fo-
cuses on maladaptive relational
patterns

▪ Transference-focused psycho-
therapy: a form of psychoanalytic
psychotherapy, developed by Otto
Kernberg, that treats borderline
personality disorder using
transference-based interpretations

▪ Time-limited dynamic psycho-


therapy: a short-term treatment
for chronic interpersonal problems
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that targets dysfunctional styles of


relating

▪ Dialectical behavior therapy:


a behavioral treatment for border-
line personality disorder with ac-
companying suicidal and parasui-
cidal behaviors that teaches four
key skills (emotion regulation,
mindfulness, distress tolerance,
and interpersonal effectiveness)

▪ Schema-focused therapy: a
cognitive behavioral therapy treat-
ment targeting borderline and nar-
cissistic personality disorders that
identifies core maladaptive schem-
as and schema-avoidance behavi-
ors that damage relationships

Unfortunately, all of these approaches


have disadvantages. Although they do target
maladaptive relational patterns, there is
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mixed empirical evidence for their effective-


ness in changing interpersonal behavior. Re-
search findings regarding the clinical impact
on clients’ interpersonal interactions are am-
biguous. Dialectical behavior therapy, for ex-
ample, has significant research support for
reducing suicidal and parasuicidal behavior,
as well as days in the hospital. Oddly,
however, the literature is vague on its ability
to change chronically ineffective interper-
sonal behavior. And while several of the cur-
rent treatments use inventories that assess
borderline personality traits, interpersonal
functioning is only a subscale of these
measures.
Although there is ample evidence that all
of these treatments are effective in reducing
hospitalizations, reducing frequency of para-
suicidal behaviors, and decreasing symptoms
related to borderline personality disorder, it
is difficult to parse their impact on changes
in interpersonal behaviors specifically. In
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addition, the field suffers from a paucity of


objective measures and inventories for as-
sessing interpersonal functioning and beha-
viors in relationships.
Moreover, each of the above therapies
fails to meet one or more of the criteria for
treating interpersonal problems outlined
above. Transference-focused psychotherapy
meets none of them, as it doesn’t target be-
havioral flexibility, pathogenic beliefs, or ex-
periential avoidance—and also doesn’t target
behavioral change, which is necessary for de-
veloping new responses to replace maladapt-
ive coping patterns. Interpersonal psycho-
therapy fails to address pathogenic beliefs
and also doesn’t provide methodologies
aimed at experiential avoidance or tolerating
emotional pain. Dialectical behavior therapy
doesn’t address pathogenic beliefs, and
schema-focused therapy doesn’t provide
techniques aimed at curtailing avoidance or
tolerating emotional pain. Time-limited
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dynamic psychotherapy is arguably the most


effective and best-targeted approach among
current treatments, yet it too doesn’t address
experiential avoidance or provide clients
with methods for tolerating the emotional
pain that drives maladaptive interpersonal
responses.
In summary, something new is needed
that more effectively targets the underlying
factors driving chronic interpersonal prob-
lems. We believe that the combination of
ACT with a schema-based formulation is that
new approach.
An Alternative Treatment Approach
This book presents a new, acceptance-based
treatment approach to interpersonal prob-
lems that targets behavioral change (and
maladaptive coping strategies in particular)
and addresses all of the criteria outlined
above:

▪ It is designed to enhance behavior-


al flexibility in interpersonal set-
tings and is focused on workability
of behavior.

▪ It addresses the role of pathogenic


beliefs, or schemas.

▪ It specifically targets experiential


avoidance by providing specific
methods for tolerating emotional
pain (such as mindfulness, self-as-
context, and cognitive defusion)
and, through values clarification,
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provides motivation for changing


avoidant behaviors.

People with interpersonal problems are


characterized by inflexible patterns of relat-
ing and are a difficult population to treat.
Given the rigidity of these patterns, ACT ap-
pears to be a beneficial treatment approach
because it promotes psychological flexibility
through building acceptance and defusing
from thoughts, emotions, and beliefs, includ-
ing schemas. ACT doesn’t attempt to change
schemas and core beliefs; rather, it alters the
way people relate to them so that they can
choose different responses to schema-related
pain and take steps in valued directions.
This book is based on long-term clinical
and research experience that has been
gained working with clients who struggle
with interpersonal problems. The ten-week
group therapy ACT protocol provided in ap-
pendix C is supported by research conducted
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by Avigail Lev (2011) testing the effective-


ness of a very similar protocol used for the
treatment of interpersonal problems. The
study was a randomized controlled trial that
was conducted at a community-based clinic
for recovery from substance abuse. The
study’s sample consisted of forty-four male
clients who were randomly assigned to con-
trol (treatment as usual) or experimental
(ACT plus treatment as usual) conditions.
(Treatment as usual was a day-treatment re-
covery program that included 12-step study,
relaxation training, anger management, re-
lapse prevention, and a host of other ser-
vices.) The major finding of the study was
that the ACT group experienced significant
decreases in problematic interpersonal beha-
viors, as measured by the Inventory of Inter-
personal Problems (IIP). Results showed
large improvements in pre- to post-treat-
ment measures of interpersonal problems in
both the mixed factorial ANOVA and the
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Cohen’s d (d = –1.23). These findings


provide strong support for the potential ef-
fectiveness of this protocol and its ability to
improve interpersonal functioning. (See ap-
pendix B for further details about and results
of this research.)
Summary
In short, none of the current treatment ap-
proaches for interpersonal problems ad-
equately target all aspects driving maladapt-
ive coping behaviors. The innovative com-
bination of ACT with a schema-based ap-
proach allows for a well-rounded treatment
protocol that addresses all of the essential
criteria. To be clear, this is an ACT treat-
ment. It doesn’t use any schema therapy
techniques; schemas are utilized solely for
the purpose of identifying clients’ primary
pain. The goal of this approach is not to
change clients’ schemas or core beliefs;
rather, the goal is to help them accept the
primary pain associated with their schemas
and assist them in improving behavioral flex-
ibility in order to enhance values-based
living.
Chapter 2
Introducing Schemas

The treatment of interpersonal problems


begins with defining early maladaptive
schemas and helping clients identify which
schemas are relevant to them and contribute
to their problematic relationships. Because
this material may be unfamiliar (not to men-
tion challenging), take your time with
it—perhaps two sessions. Then you can move
on to helping clients identify common
schema triggers so they can begin to bring
more mindful awareness to these situations
as they occur. Once clients are aware of how
schema-driven thoughts, emotions, and be-
haviors are impacting their interpersonal in-
teractions, they have more opportunity—and
more motivation—to change their behavior.
Understanding Schemas
A schema is a core belief that’s generated in
early childhood as a result of an individual’s
experiences with parents, caregivers, sib-
lings, and peers. Schemas are deeply rooted
cognitive structures and beliefs that help
define a person’s identity in relationship to
others. As such, schemas exert a huge influ-
ence over interpersonal behavior and are the
driving force behind interpersonal problems.
Early maladaptive schemas are very power-
ful for a number of reasons (Young and
Klosko, 1993):

▪ They include unconditional beliefs


about who we are and what we can
expect in relationship to others and
the world. They are experienced as
a priori truths and are taken for
granted.
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▪ They are self-perpetuating and res-


istant to change because they de-
velop in early childhood and ad-
olescence. They can be experienced
in the first few years of life and can
therefore be preverbal.

▪ They are derived from early


trauma, neglect, and repeated neg-
ative messages about the self. As a
result, they form the core of self-
concept.

▪ They are tied to high levels of dis-


tressing emotion, or schema affect.
Typically, schema affect includes
fear, shame, loneliness, a sense of
emotional hunger or yearning, an-
ger, or a combination of these.

▪ They are activated by relevant


events. For example, a failure
schema is often activated by
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criticism or confronting a challen-


ging task.

▪ They attempt to predict the future.


Schemas help organize people’s
knowledge about interactions
between themselves and the world.
At root, schemas are efforts to
identify what will happen in every
circumstance of every relationship.
Because these beliefs offer the illu-
sion that one can peer into the fu-
ture and prepare for it, they are ex-
tremely hard to give up.
The Role of Unmet Early Childhood Needs
Maladaptive schemas are created when early
childhood core needs aren’t met. According
to Jeffrey Young (Young, 2004), six needs
must be met for children to thrive. If neg-
lected, these needs create schemas that are
problematic for people and their interper-
sonal relationships.

▪ Basic safety. Essential at birth,


this need involves how children are
treated by their family or care-
givers. When infants or small chil-
dren aren’t provided with a stable
and safe environment, they may
develop an abandonment and in-
stability schema, a mistrust and
abuse schema, or both.

▪ Connection to others. When


children don’t receive love, affec-
tion, empathy, understanding, and
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guidance from family members or


peers, they may develop an emo-
tional deprivation schema, a social
isolation and alienation schema, or
both.

▪ Autonomy. Essential for child-


hood development, autonomy al-
lows for healthy independence and
separation from parents. When
children aren’t taught self-reliance,
responsibility, and good judgment,
they are likely to develop a depend-
ence and incompetence schema or
a vulnerability schema. (Vulnerab-
ility isn’t one of the ten schemas in-
cluded in this treatment protocol.)

▪ Self-esteem. When children are


loved, accepted, and respected,
they develop self-esteem. When
family and peer support are ab-
sent, children may develop a
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defectiveness and shame schema, a


failure schema, or both.

▪ Self-expression. In a nurturing
environment, children are encour-
aged to express their needs and de-
sires. When this self-expression is
discouraged, children are made to
feel that their needs and feelings
matter less than those of their par-
ents. Often these children are pun-
ished and made to feel “less than.”
When self-expression isn’t encour-
aged and supported, children may
develop a subjugation schema or
an unrelenting standards and hy-
percriticalness schema.

▪ Realistic limits. When children


are raised in an environment that
encourages responsibility, self-
control, self-discipline, and respect
for others, they learn to operate
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within realistic limits. When par-


ents are permissive and overly in-
dulgent, children grow up without
understanding the need to con-
sider other people before acting. In
the absence of realistic limits, chil-
dren may develop an entitlement
schema.
Explaining Schemas to Clients
You can either explain to clients the proper-
ties of schemas as outlined in the handout
Understanding Early Maladaptive Schemas,
or you can give them the handout to read.

Understanding Early
Maladaptive Schemas

A maladaptive schema is essentially a be-


lief about yourself and your relationship
to the world. It creates a feeling that
something is wrong with you, your rela-
tionships, or the world at large. Schemas
are formed in childhood and develop as a
result of ongoing dysfunctional experi-
ences with parents, siblings, and peers
during childhood, and they continue to
grow as children try to make sense of
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their experience and avoid further pain.


Schemas come from repeated toxic mes-
sages that we get about ourselves from
our early experiences (for example,
“You’re bad” or “You can’t do anything
right”) or from specific traumatic events.
Once a schema is formed, it’s extremely
stable and becomes an enduring pattern
that is repeated throughout your life.

Schemas are like sunglasses that distort


all of your experiences. They color the
way you see things, and they make as-
sumptions and predictions that tell you
the schema is true or will turn out to be
true. Schemas formed during childhood
are triggered repeatedly throughout your
adult life. Common triggers include
stressful interpersonal events and difficult
thoughts and feelings. Once a schema is
triggered, it brings up powerful automatic
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thoughts and feelings about yourself that


can lead to depression, panic, loneliness,
anger, conflict, inadequate work perform-
ance, addiction, and poor decision mak-
ing. Schemas interfere with your ability to
feel safe in relationships, your ability to
get your needs met, and your ability to
meet the needs of others.

Characteristics of Early Maladapt-


ive Schemas

They are experienced as self-evident


truths about yourself or your
environment.

They are self-perpetuating and res-


istant to change.

They seem to predict the future, par-


ticularly what will happen in relation-
ships. And because they create the
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illusion that you can see what’s com-


ing and prepare accordingly, they are
extremely difficult to give up.

They’re usually triggered by stressful


events, typically something painful in
a relationship that activates old be-
liefs about yourself.

They are always accompanied by


high levels of emotion, such as
shame, fear, hurt, or despair.
Identifying Clients’ Schemas
There are ten schemas associated with inter-
personal problems. Each of these core beliefs
has the capacity to disrupt and damage inter-
personal interactions. Most clients have
more than one schema influencing relation-
ships, and several schemas may work in con-
cert to create significant distress. For ex-
ample, a defectiveness and shame schema of-
ten shows up with an abandonment and in-
stability schema, so the belief that one is un-
lovable ends up driving the expectation that
one will be rejected. You can use the descrip-
tions in the Ten Key Schemas handout to ex-
plain these schemas to clients. We also re-
commend giving them the handout to study
and refer to in the weeks to come.

Ten Key Schemas


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Psychologist Jeffrey Young has identified


eighteen early maladaptive schemas. Ten
of these schemas have significant relev-
ance to interpersonal relationships. A
schema is a core belief. Core beliefs
define who we are and direct how we live
our lives. They create the internal mono-
logue that characterizes the thoughts, as-
sumptions, and interpretations that in-
form each person’s individual worldview.
When a schema is activated, it produces
intense emotions. Identifying your
schemas and examining how they impact
your life and your interactions with others
is essential to making positive changes in
your relationships. Study this list of the
ten schemas relevant to problems in in-
terpersonal relationships and keep it
handy so you can identify which schemas
are affecting your interactions:
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Abandonment and instability: the


belief that significant people in your
life are unstable or unreliable

Mistrust and abuse: the expecta-


tion that you will be harmed through
abuse or neglect

Emotional deprivation: the expect-


ation that your needs for emotional
support won’t be met, which may
take several forms:

• Deprivation of nurturance:
the absence of attention

Deprivation of empathy:
the absence of
understanding

Deprivation of protection:
the absence of guidance
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Defectiveness and shame: the be-


lief that you are defective, inferior,
or unlovable

Social isolation and alienation:


the belief that you don’t belong to a
group, are isolated, or are radically
different from others

Dependence and incompetence:


the belief that you are incapable or
helpless and require significant as-
sistance from others, that you can-
not survive without a certain person,
or both

Failure: the belief that you are inad-


equate or incompetent and will ulti-
mately fail

Entitlement: the belief that you de-


serve privileges and are superior to
others
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Subjugation: voluntarily meeting


the needs of others at the expense of
your own needs, submitting to others
to avoid real or perceived con-
sequences, or surrendering control to
others due to real or perceived
coercion

Unrelenting standards and hy-


percriticalness: the belief that you
must meet very high internalized
standards to avoid criticism, leading
to impairment in such areas of life as
pleasure, health, and satisfying
relationships
Schema Affect
As mentioned earlier, each schema is associ-
ated with one or more painful emotional
states. Once a schema is triggered by inter-
personal events, the relevant schema affect
immediately shows up and begins influen-
cing the person’s behavior. The following
table identifies the typical affects for each of
the ten schemas.

The emotions associated with schemas


are so painful that people are often
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motivated to do anything to cope with or try


to avoid them. We’ll examine this in detail in
chapter 3.
Assessing Schemas
We recommend three approaches to identi-
fying early maladaptive schemas:

▪ Having the client fill out a schema


questionnaire, such as the Young
Schema Questionnaire

▪ Reviewing thought logs filled out


by the client

▪ Using imagery to trigger and


identify schemas

Schema Questionnaires
The Young Schema Questionnaire has
been widely used to identify the eighteen
early maladaptive schemas. In appendix A,
we’ve adapted the Young Schema Question-
naire, with the permission and assistance of
Jeffrey Young, PhD, to specifically identify
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the ten schemas that are relevant to interper-


sonal problems. Note that the version in ap-
pendix A is just for reference. If you wish to
use a similar questionnaire in your practice,
please visit schematherapy.com, where you
can purchase the most current version of Jef-
frey Young’s questionnaire for research or
clinical use.

Thought Logs
A simple thought log can be a gateway to
understanding clients’ schemas. Over a peri-
od of one to two weeks, have clients keep a
record of their thoughts using the Thought
Log. Instruct them to use the log after exper-
iencing strong emotional reactions, such as
sadness, anxiety, shame, or anger, and ask
that they record all significant thoughts ex-
perienced during the period of high affect,
describing triggering situations in the left-
hand column, emotional reactions in the
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middle column, and key automatic thoughts


in the right-hand column.
When you review the thought log, choose
several thoughts that appear to be related to
schemas. Then use the downward arrow
technique to probe whether thoughts indic-
ate operative schemas. In this technique,
you’d ask, “If [the thought] is true, what does
that mean about you?” Encourage the client
to answer in terms of thoughts and beliefs,
not feelings. Keep asking this key question
about each successive thought or belief until
the client describes a thought or belief that
fits one of the schemas. Here’s an example
dialogue:
Therapist: Your thought log includes a
thought I want to explore with you.
When your daughter resisted doing
her homework with you, you
thought, “I can’t stand this.” If it
were true that you can’t stand this,
what would it mean about you?
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Client: It means I can’t deal with her…can’t


deal with her resistance, the way
she just ignores what I want her to
do.
Therapist: And if it’s true that she resists you
and ignores what you want her to
do, what does that mean about you?
Client: It means I’m a screwed-up par-
ent—that I don’t know what I’m
doing.
Therapist: And if it’s true that you don’t
know what you’re doing as a parent,
what does that mean about you?
Client: It means I’m incompetent. I screw up
everything that matters to me.
Notice that it doesn’t take long to get
down to the schema that this client is strug-
gling with: failure. If you use the downward
arrow technique to inquire about what a par-
ticular thought means about the client, you’ll
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eventually arrive at the underlying core be-


lief—and schema—driving the thought.

Imagery
To use imagery to trigger and identify
schemas, start by identifying a recent situ-
ation that created high affect and might be
related to a schema. Ask clients to visualize
the scene, noticing what they saw, heard, and
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felt (both physically and emotionally). When


they are sufficiently immersed in the scene to
experience some affect, ask these questions:

▪ Who are you in the scene?

▪ What does viewing this scene make


you feel about yourself?

▪ In this scene, what do you fear will


happen?

▪ How does the other person see you


in this scene?

▪ What are you telling yourself dur-


ing this scene?

The answers to these questions often


provide a relatively clear indication of which
schema is involved.
Giving Feedback to Clients
Whether you use a schema questionnaire,
thought logs and the downward arrow tech-
nique, or imagery, the assessment process
will help you identify one or more key
schemas that are driving clients’ interperson-
al problems. Then you can use the Ten Key
Schemas handout from earlier in this
chapter to define and discuss relevant
schemas with clients. As you do so, verify
that clients recognize the schema-related
core beliefs as part of their thinking. Here’s
an example dialogue showing how to achieve
this:
Therapist: When we looked at your thought
record, there was something that
came up over and over again. It was
the thought that you don’t fit any-
where—the sense that no one sees
or understands you. And when we
looked at the different schemas on
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that list, social isolation seemed to


really fit for you—this feeling of not
belonging, of being alone even
when you’re with people. Is that
feeling of not fitting in something
that’s familiar? Has it shown up at
other times in your past?
Client: Yes. I felt just like that in my family.
They were these loud, high-energy
people, and I always felt meek and
quiet. They just ran over me with
their energy. I felt that in high
school too, and in college. I just
didn’t belong to the groups around
me.
Therapist: And later, in your adult life, has
that also felt true?
Client: I feel like people don’t get me, almost
like I’m a nonentity to them. I feel
like I’m on the outside looking in.
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Therapist: So the schema of not fitting, of be-


ing somehow isolated from others,
stretches all the way from child-
hood to things you feel right now.
As you work with clients to identify their
schemas, don’t be attached to labels and de-
scriptions from this book (or elsewhere). It’s
often a good idea to use clients’ language to
describe and label their schema experience,
as illustrated in the preceding dialogue.
Helping Clients Recognize Schema Affect
Once you’ve confirmed the schema or
schemas that influence clients’ interpersonal
interactions, you can begin to explore
schema-related affect. To help clients link
their schemas to emotions, you can ask dir-
ect questions; for example, “When that de-
fectiveness schema shows up, what emotion
seems to go with it?” or “When you begin to
have that sense of emotional deprivation and
you think you won’t get what you need, what
feeling comes up with that?”
Clients usually have a very clear sense of
the affect that arises when their schemas are
triggered. They’re well aware of the emotion-
al pain that suddenly wells up in those situ-
ations. As you talk about schemas, always ac-
knowledge the schema-related emotions that
begin to hammer clients when schemas are
activated. It’s important to recognize and
validate clients’ emotional state so that you
can work together to tackle the schema-
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driven affect and maladaptive coping


behavior.
Schema Triggers
Virtually any interpersonal situation can po-
tentially trigger schemas and schema affect.
Once clients are aware of their schemas and
the emotional impact of those schemas, you
can work on identifying the interpersonal
situations that most typically trigger schem-
as. You can explain these situations to clients
as outlined in the Schema Triggers handout.
We recommend that you also give clients the
handout for their reference.

Schema Triggers

Schemas distort our view of others and


interpersonal situations. When our
schemas get triggered, we react in ways
designed to protect ourselves from the
emotional pain that results. Triggers are
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unavoidable. However, if you can identify


the triggers for each of your schemas and
consciously notice when those situations
arise, you’ll be one step closer to chan-
ging the reactions that typically follow,
and therefore one step closer to minimiz-
ing the pain associated with the schema
and the problematic coping behavior that
follows. Here are some of the typical trig-
gers for each schema:

Abandonment and instability.


This schema is likely to be triggered
when you’re with someone who is
unpredictable, unstable, or unavail-
able. When this schema is triggered,
you’ll experience anger, fear, and
grief.

Mistrust and abuse. This schema is


likely to be triggered when you be-
lieve that people you’re interacting
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with will hurt or betray you. When


this schema is triggered, you’ll ex-
perience anger, fear, and yearning.

Emotional deprivation. This


schema is likely to be triggered if
you feel lonely, if you’re with a de-
tached partner, or if you don’t feel
understood, protected, or loved.
When this schema is triggered, you’ll
experience sadness, loneliness, and
anger.

Defectiveness and shame. This


schema is likely to be triggered when
you start to get close to someone
and feel that your defects will be ex-
posed, when others criticize you, or
when you’re in a situation that
makes you feel that others will find
you inadequate, flawed, or unworthy.
When this schema is triggered, you’ll
experience shame, anger, and
sadness.
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Social isolation and alienation.


This schema is likely to be triggered
when you’re in situations or groups
of people and feel different or left
out. When this schema is triggered,
you’ll experience fear, anxiety, an-
ger, loneliness, and shame.

Dependence and incompetence.


This schema is likely to be triggered
by any life changes or new situations
or the end of a relationship with
someone you rely on heavily. When
this schema is triggered, you’ll ex-
perience anxiety, fear, and anger.

Failure. This schema is likely to be


triggered when you’re with people
who are more successful than you or
when you’re in situations that make
you feel that you’re lacking in terms
of accomplishments, talents, com-
petence, or intelligence. When this
schema is triggered, you’ll
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experience sadness, shame, anger,


and fear.

Entitlement. This schema is likely


to be triggered when things don’t go
your way or when your needs and
desires aren’t put first. When this
schema is triggered, you’ll experi-
ence anger.

Subjugation. This schema is likely


to be triggered when you’re in situ-
ations and relationships where the
needs of others come first or where
you feel controlled by others. When
this schema is triggered, you’ll ex-
perience sadness and anger.

Unrelenting standards and hy-


percriticalness. This schema is
likely to be triggered when you feel
that you or others haven’t met your
high standards. When this schema is
triggered, you’ll experience anger.
Interpersonal Domains
Events that can trigger schemas occur within
six interpersonal domains: work, friends,
family, intimate relationships, parenting,
and community. Bring the focus to these do-
mains to help clients identify and under-
stand their vulnerability to schemas in a
variety of relationships. For each domain,
ask, “With regard to your schema [ideally,
you’d mention a specific schema], what situ-
ations seem to trigger it at work?” If clients
identify a particular interpersonal event,
keep pushing. Ask if there are additional ex-
periences, conflicts, or interactions that ac-
tivate the schema and its related affect. Keep
asking until you’ve identified as many situ-
ations and interpersonal events as possible.
Use the Schema Triggers Worksheet to list
these situations. Work through all relevant
domains to identify a number of schema-
triggering events that the client struggles
with across a wide range of situations.
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Encourage clients to observe schema-


triggering events as they occur and note the
related affect as it emerges. However, also
explain that the point is not to control trig-
gers and the accompanying painful emo-
tions; rather, the point is to learn to recog-
nize when schemas and schema-related af-
fect are activated in relationships. To help
clients develop this awareness, you can give
them the Schema Events Log and ask them
to complete it as homework, recording trig-
gers and emotions any time they notice that
a schema has been activated.
The Schema Events Log is designed to
help clients recognize and observe schema-
related events as they occur. The more cli-
ents are able to mindfully watch schema-
triggering events, the more likely it is that
they’ll be able to exert control over their re-
sponses in the future.
It’s important to acknowledge and valid-
ate the painful emotions associated with
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each schema-triggering event. When experi-


encing painful emotions, it’s a natural reac-
tion to want to escape the pain. It’s useful to
help clients observe and document each step
of the triggering process. The more clients
know about their triggers and the better they
can recognize them as they occur, the greater
the chances that they will be able to change
problematic interpersonal behaviors. The
following example dialogue shows how you
can do this:
Therapist: (Looks at the client’s Schema
Events Log.) I see your coworker
said something that felt very
critical.
Client: Yeah, that I don’t seem to give a shit
about the job—that I look
disinterested.
Therapist: And that seemed to activate your
defectiveness schema?
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Client: Yeah. I felt sick, like I was really


screwing up. And then I started to
get angry, like who the hell is this
person?
Therapist: So it felt like something was
wrong with you, and that was…
Client: Like a kick in the stomach. It was this
worthless feeling.
Therapist: And then you got angry.
Client: I told her to mind her fucking busi-
ness and said that I didn’t care what
she thought.
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ACT and Schemas
ACT recognizes that pain is inherent in hu-
man existence. From the ACT point of view,
schema-related pain isn’t pathological, nor is
it something that can be overcome. Because
schema-related pain has its origins in early
childhood, it is an enduring part of the indi-
vidual’s experience. No matter what age we
are or how long we have been in therapy, we
are unlikely to fully emancipate ourselves
from schemas and schema-related affect. For
example, among people who had early aban-
donment experiences and learned to expect
them, the abandonment and instability
schema is likely to be triggered during every
relevant interpersonal event. The criticism,
withdrawal, and anger of others will activate
the schema and the fear that goes with it.
The focus of ACT for interpersonal prob-
lems is not to eliminate schemas and
schema-related pain; rather, it is to learn to
respond differently when schemas are
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triggered. ACT makes a clear distinction


between the primary pain that is part of the
human condition and the secondary pain, or
suffering, that results from the struggle to
avoid the unavoidable. From the ACT point
of view, schema affect is primary pain—an
unavoidable by-product of living. Therefore,
the target of the treatment protocol in this
book is not to stop or block the primary pain
related to schema activation. Instead, the fo-
cus is on easing secondary pain: the suffering
generated by attempts to avoid schema
affect.
Schema coping behaviors (SCBs) lie at
the root of interpersonal problems. Whenev-
er people try to avoid or block primary pain
due to schemas, relationships sustain dam-
age. Therefore, the focus of this treatment is
on clients’ schema coping behaviors. SCBs
correspond to the ACT concept of experien-
tial avoidance, which involves maladaptive
strategies to suppress, numb, manage, and
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control pain. From an ACT point of view, the


problem isn’t schemas or the emotions they
generate; the problem is trying to avoid
schema-related pain with a variety of
strategies that damage or destroy
relationships.
Summary
As clients begin to observe their schema trig-
gers and reactions in day-to-day life, they’ll
develop a growing awareness of the powerful
role schemas play in interpersonal events. In
the next chapter, we’ll focus on schema cop-
ing behaviors, which are a form of experien-
tial avoidance, and how they damage rela-
tionships. Helping clients develop an under-
standing of this dynamic is essential to creat-
ing motivation for the arduous work ahead:
learning to accept schema-related pain in the
service of values-based interpersonal
behavior.
Chapter 3
Understanding Schema Coping Behaviors

After helping clients understand schemas,


their roots in childhood experiences, and the
powerful role they play in everyday life and
relationships, you can begin to explain
schema coping behaviors and assess their
costs. Although these behaviors often
provide a bit of short-term relief, they usu-
ally damage relationships in the long run. As
mentioned, understanding this can provide
clients with powerful motivation to engage in
the challenging work of changing long-term
patterns of behavior in relationships.
Introducing Schema Coping Behaviors
Here’s an example of how you might intro-
duce schema coping behaviors to clients:
Therapist: Schema coping behaviors are re-
sponses aimed at blocking or
controlling schema-related pain.
These coping behaviors may offer
temporary relief in the moment, but
in the long run they contribute to
the schema, make it feel more true,
and actually increase schema-re-
lated emotional pain.
Both environment and temperament can
contribute to the formation of
schema coping behaviors. We often
learn these coping behaviors by
watching our parents and other
family members deal with pain.
Dad may have gotten angry and
gone on the attack when he was
hurt. Mom may have collapsed and
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given up. A sister may have with-


drawn in her bedroom. A brother
may have started to drink.
In addition, sometimes we come up with
schema coping behaviors on our
own. When a schema is triggered,
over time we learn a way of re-
sponding that feels like it offers at
least temporary relief from the in-
tense emotional pain. Because it
seems to work, we stick with it, do-
ing the same thing again and again
in similar situations.
The trouble with schema coping behaviors is
that they tend to hurt other people,
relationships, and, ultimately, the
person who’s using them. When we
withdraw, surrender, or go on the
attack, relationships stop feeling
good to the people who are import-
ant to us. After a while they may
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give up on us or harden and with-


draw. So, although schema coping
behaviors may offer some tempor-
ary relief, in the long run they make
us feel worse about ourselves—and
may cause us to lose people we love.
Common Schema Coping Behaviors
Although schema coping behaviors are
highly individualized, they tend to follow
similar patterns. The SCBs most damaging to
interpersonal relationships can be broadly
classified into ten types, described in the
handout Ten Common Schema Coping Beha-
viors (Young, 2012). The first five schema
coping behaviors all involve overcompensa-
tion. The easiest way to understand this type
of coping behavior is to think of it as a more
aggressive response to a schema-triggering
event. When people engage in one of these
coping responses, they are fighting the
schema. This is akin to the “fight” part of the
fight, flight, or freeze reaction. The sixth
schema coping behavior involves surrender.
It can best be described as a more passive re-
sponse to a schema-triggering event. Think
of it as the “freeze” aspect of the fight, flight,
or freeze reaction to the schema-triggering
event. The last four schema coping behaviors
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involve avoidance. These responses to


schema-triggering events are attempts to
avoid the pain associated with those events.
Think of them as the “flight” component of
the fight, flight or freeze response.
You can use the Ten Common Schema
Coping Behaviors handout to describe mal-
adaptive behaviors to clients, then give them
the handout for their reference.

Ten Common Schema


Coping Behaviors

Overcompensation

Aggression or hostility: If you use


this coping behavior in response to a
schema-triggering event, you’ll find
yourself counterattacking by
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blaming, criticizing, challenging, or


being resistant.

Dominance or excessive self-as-


sertion: If you use this coping beha-
vior in response to a schema-trigger-
ing event, you’ll find yourself trying
to control others in order to accom-
plish your goals.

Recognition seeking or status


seeking: If you use this coping be-
havior in response to a schema-trig-
gering event, you’ll find yourself
overcompensating by trying to im-
press others and get attention
through high achievement and
status.

Manipulation or exploitation: If
you use this coping behavior in re-
sponse to a schema-triggering event,
you’ll find yourself trying to meet
your own needs without letting
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others know what you’re doing. This


may involve the use of seduction or
not being completely truthful to
others.

Passive-aggressiveness or rebel-
lion: If you use this coping behavior
in response to a schema-triggering
event, you’ll appear to be compliant
but will rebel by procrastinating,
complaining, being tardy, pouting, or
performing poorly.

Surrender

Compliance or dependence: If you


use this coping behavior in response
to a schema-triggering event, you’ll
find yourself relying on others, giving
in, being dependent, behaving pass-
ively, avoiding conflict, and trying to
please others.
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Avoidance

Social withdrawal or excessive


autonomy: If you use this coping
behavior in response to a schema-
triggering event, you’ll find yourself
isolating socially, disconnecting, and
withdrawing from others. You may
appear to be excessively independ-
ent and self-reliant, or you may en-
gage in solitary activities, such as
reading, watching TV, computer use,
or solitary work.

Compulsive stimulation seeking:


If you use this coping behavior in re-
sponse to a schema-triggering event,
you’ll find yourself seeking excite-
ment or distraction through compuls-
ive shopping, sex, gambling, risk
taking, or physical activity.

Addictive self-soothing: If you use


this coping behavior in response to a
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schema-triggering event, you’ll find


yourself seeking excitement with
drugs, alcohol, food, or excessive
self-stimulation.

Psychological withdrawal: If you


use this coping behavior in response
to a schema-triggering event, you’ll
find yourself escaping through disso-
ciation, denial, fantasy, or other in-
ternal forms of withdrawal.

Although these categories are helpful, it’s


important to keep in mind that clients may
have different coping behaviors for different
schemas, or even different coping behaviors
for the same schema. For example, a client
with an emotional deprivation schema may
sometimes demand that his or her needs be
met and at other times give in or surrender.
It is critical to work with clients to identify
all the coping strategies they use to avoid
schema-related pain.
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Once you’ve introduced the concept of


schema coping behaviors and clients have
had a chance to review the handout, you can
begin a general discussion about which SCBs
they use most often. The following dialogue
provides an example of how to begin explor-
ing the role of SCBs. The client in this dia-
logue has a social isolation and alienation
schema:
Therapist: When you look over that list—the
ways people tend to cope with the
emotional pain from their schem-
as—is anything familiar?
Client: Withdrawal. Total disconnection. It’s
like, “Screw it. What are you both-
ering with these people for?”
Therapist: Anything else? What comes up
when you see how different from
you other people are, or when they
seem caught up in their lives and
pretty much unaware of you?
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Client: Anger. I get very critical and disgus-


ted. If I don’t feel included in
something, I can go on the attack.
Therapist: So when you feel excluded—not
belonging or not part of things—you
can go either way: withdrawing or
being more critical or perhaps at-
tacking. Do you have any sense of
why you’d choose one or the other
of these coping behaviors?
Client: I think I get angry when I try to make
my needs known and people don’t
get it—when they don’t seem to
have any concern for me.
Linking SCBs to Specific Interpersonal
Situations
Next, clients need to link schema coping be-
haviors to particular relational triggers. To
achieve this, help them examine schema-
triggering situations and the resulting SCBs
in each of the six interpersonal domains:
work, friends, family, intimate relationships,
parenting, and community. Completed
Schema Events Logs, from chapter 2,
provide a list of schema-triggering situ-
ations. Have clients transfer these to the left-
hand column of the Schema Coping Behavi-
ors Worksheet. (A sample filled-out work-
sheet follows the blank form.)
At this point in the treatment process, cli-
ents may know a good deal more about
schema triggers than when they first filled
out the Schema Events Log, so encourage
them to write down as many additional trig-
gering situations as they can think of. The
more comprehensive this list is, the better
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prepared clients will be to recognize schema-


triggering events when they occur.
Next, for each schema-triggering situ-
ation, have clients identify their schema cop-
ing behavior and describe it in the right-
hand column. If they have any difficulty
identifying their coping behaviors, have
them review the Ten Common Schema Cop-
ing Behaviors handout. The following brief
visualization may also help:

1. Ask the client to visualize a specific


triggering situation.

2. Ask the client to notice the emotion


that situation sets off and to name
the schema.

3. Ask the client to notice any action


impulses that arise while visualiz-
ing the situation. What does the
client want to say or do to cope
with the pain?
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Examining the Costs of SCBs
Once clients have recognized the link
between schema triggers and SCBs, do an in-
depth exploration of some of the most salient
triggering situations—those where schema
coping behaviors are impacting important
relationships. The goal is for clients to differ-
entiate between the short-term and long-
term effects of these behaviors. Here’s a dia-
logue that exemplifies this process, based on
the sample worksheet filled out by Beth:
Therapist: There are a couple of triggering
situations with your husband: when
he criticizes something you do, and
when he seems kind of clipped,
cold, and uncommunicative.
Beth: Yes. I feel vulnerable with him.
Therapist: Because he can trigger that feeling
of unworthiness—the defectiveness
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schema, the sense that you’re some-


how wrong or bad.
Beth: Right.
Therapist: So let’s look at how you cope. (Ex-
amines Beth’s worksheet.) When he
criticizes, you counterattack—you
get angry and talk about all the
things he does wrong. But when
he’s cold and withdrawn, you find
yourself clinging and demanding at-
tention. Those are two very differ-
ent coping responses.
Beth: When he criticizes, I feel hurt…and
ashamed. And I can’t stand that, so
I blow up. But his withdrawal is
scary. I feel like he’s getting sick of
me. So I try to pull him close.
Therapist: When you use those schema cop-
ing behaviors—getting angry or try-
ing to pull your husband
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close—does it make you feel better


or worse?
Beth: I guess I feel better at first. When I
lash out, I don’t feel as bad about
myself. And when I get clingy and
demanding, I feel like I’m holding
on to him, so I’m a little less scared.
Therapist: And then what? Does the schema
coping behavior continue to help
you?
Beth: No. He gets annoyed, and then I feel
like something has gone wrong
between us.
Therapist: So the coping behavior helps in
the short term, but after a while…
Beth: Yeah. I feel like I’m screwing things up.
Therapist: So the coping behaviors aren’t a
long-term solution. They seem like
they might even strengthen that old
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schema—the sense of being


unworthy.
As in the above dialogue, work with cli-
ents to examine their most powerful triggers
and SCBs. The goal is to help clients see that
schema coping behaviors provide short-term
relief from schema affect but that over time
they tend to strengthen schemas and actually
produce more schema-related pain. During
this exploration, clients may develop a grow-
ing recognition of how SCBs impact their re-
lationships in different domains.
Encourage clients to recognize their most
common SCBs and which interpersonal situ-
ations typically trigger particular coping re-
sponses. With this awareness, clients can be-
gin to watch for these triggering situations
and notice how they react. Explain that
changing behavior starts with recognition:
seeing SCBs when or soon after they occur.
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Examining schema coping behaviors is


hard. Listing and discussing these maladapt-
ive responses can trigger significant shame.
It can also activate various schemas, particu-
larly defectiveness and failure. Be gentle with
this material. Validate how painful it feels
when schemas are triggered and how normal
it is to do almost anything to stop or mask
that pain. As you discuss SCBs, try to de-
scribe the behavior nonpejoratively. If SCBs
show up in the session directed toward
you—for example, attack, withdrawal, or sur-
render behaviors—supportively describe
what the client is doing, identify the schema
that has been triggered, and validate the
pain. Then have the client add the in-session
triggering situation to the Schema Coping
Behaviors Worksheet.
For homework, encourage clients to keep
observing schema triggers throughout the
week and to use the Schema Coping
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Behaviors Worksheet to document any SCBs


they engaged in.
ACT and SCBs
As you explore the long-term results of
schema coping behaviors with clients, it
should become obvious that these behaviors
have strained many relationships—and that,
despite damaged and lost relationships, the
pain associated with their schemas contin-
ues. This makes it clear to clients that trying
to avoid schema-related pain with SCBs
doesn’t ultimately get rid of the pain. If any-
thing, it can exacerbate the pain over time.
As noted in chapter 2, schema-related
pain is inevitably triggered in relevant inter-
personal situations. ACT calls this unavoid-
able experience primary, or “clean,” pain. In
essence, SCBs are always attempts to avoid
this unavoidable pain. Although each SCB
looks different behaviorally, all share the
same purpose—to avoid or temporarily block
schema affect. This leads to what ACT de-
scribes as secondary, or “dirty” pain: suffer-
ing that results from avoidance and
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maladaptive choices. This secondary pain is


the target of treatment, and diminishing
such suffering is the goal of ACT.
Summary
This final introductory step of treatment
provides clients with a more complete un-
derstanding of how schemas work. As they
identify specific avoidance strategies and the
interpersonal situations in which they are
employed, clients begin to see a pattern and
become familiar with their particular coping
response repertoire.
As you normalize SCBs and validate their
role in the management of schema-related
pain, you can also begin to reveal the role
these behaviors play in schema maintenance
and how they damage relationships in the
long term. The next chapter begins to apply
ACT principles and processes to this theme
as you examine the specific emotional and
relational costs of SCBs.
Chapter 4
Cultivating Creative Hopelessness and
Developing Mindfulness Skills

Thus far, you’ve helped clients identify


their schemas relevant to interpersonal in-
teractions and the schema coping behaviors
they tend to engage in. This chapter will
guide you in helping clients assess the costs
of those SCBs and how they impact relation-
ships in the key domains of work, friends,
family, intimate relationships, parenting,
and community life. This lays the ground-
work and provides motivation for the ACT
approach known as creative hopeless-
ness—the territory where new solutions and
behaviors can be discovered.
An important part of this process is ex-
ploring workability by assessing the impact
of SCBs on clients’ relationships. Workability
immediately precedes creative hopelessness.
When exploring workability, help clients
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recognize the outcomes of their schema cop-


ing behaviors. Also explore whether these
behaviors help them feel better, whether
they improve relationships, and whether
they bring clients closer to their values. Re-
cognizing the costs of SCBs and that they
aren’t workable in the long run helps clients
arrive at creative hopelessness—the point
where they realize that their schema-related
pain is unavoidable and that the problem
isn’t the pain but rather attempts to avoid
this pain. Workability and creative hopeless-
ness are both processes that continue to oc-
cur and need to be addressed throughout
therapy.
This chapter also covers teaching clients
mindfulness skills—one of six core processes
in ACT. These skills aren’t intended as
stress-reduction techniques; rather, they
help clients develop more awareness of
schema affect and the urge to engage in
SCBs. They also help create space for clients
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to make more authentic choices—values-


based choices—about how they wish to re-
spond to schema-related pain and the urge
to engage in SCBs.
Assessing the Costs of SCBs
You can use either a formal or an informal
approach to help clients evaluate the costs of
SCBs in significant relationships. Either way,
take a session or two to explore this topic
and assess the costs in a wide range of rela-
tionships in all relevant domains. Appreciate
and validate the pain these SCBs create.
Mourn, for a moment, the losses that truly
mattered and acknowledge the weight of
these relational difficulties. The motivation
to change is largely driven by such experi-
ences, so the time you devote to this aspect
of the therapy will pay dividends later on.

Formal Assessment of the Costs


For a formal exploration of the costs of
SCBs, ask clients to fill out the Outcomes
Worksheet. For each significant SCB, have
clients identify negative outcomes in the six
interpersonal domains. Obviously, not all
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domains will be negatively affected; those


that aren’t relevant may be left blank. (A
sample filled-out worksheet follows the
blank form.)
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Because clients using the Outcomes


Worksheet often focus on behavioral
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consequences—things that happened—you


may need to direct them toward exploring
emotional outcomes. Ask whether they ex-
perienced sadness, loss, loneliness, hurt,
guilt, shame, or fear in any domain as a res-
ult of SCBs. As mentioned above, this emo-
tional pain can provide motivation for the
difficult work ahead, so take your time re-
viewing this material.

Informal Assessment of the Costs


An alternative to the Outcomes Work-
sheet is tracing outcomes for one or more
SCBs on a whiteboard. You probably don’t
need to write down all the domains; just
work with the client collaboratively to list as
many problematic outcomes as possible. At
some point during the whiteboard work, ex-
press your growing concern about how much
pain these SCBs have caused and the
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difficulty of the struggles they’ve created in


the client’s life.
An even less formal assessment of SCB
outcomes can be done by asking about sever-
al key domains and how schema coping be-
haviors have impacted relationships in those
domains. Encourage the client to tell some
stories about this, then explore a few of the
painful outcomes in depth. Afterward, sum-
marize and validate, as illustrated in the fol-
lowing example:
Therapist: I’m starting to really understand
how that coping strategy of with-
drawing and shutting down has af-
fected you. The old schema-related
pain—feeling somehow wrong and
defective—would clobber you. You
didn’t know how to protect yourself
from those feelings except by shut-
ting down. It was all you could do,
and for a little while it seemed to
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insulate you from the pain.


(Validation.)
But while withdrawing seemed to protect
you, it was damaging your relation-
ships. (Assessing the cost of SCBs.)
Your wife got lonely and was kind of
dying on the vine. And finally she
just drifted away, which triggered a
tremendous amount of loneliness in
you. At work, when you got criti-
cized and had those “something’s
wrong with me” feelings, you often
pulled away and moved on to an-
other job. But that meant starting
over somewhere else, and it kept
putting your career back. I hear a
lot of regret about that now.
And then there was your father—a kind of
gruff, hard-boiled guy who hurt you
with his opinions. So you pulled
away, and then you never really got
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a chance to say good-bye when he


died. There’s a lot of sadness about
that.
And now, when your girlfriend asks you to
change something or complains, it
sets off the same feelings. Then you
shut down, and she withdraws from
you in turn.
As I listen, I can feel how much you’ve lost
because of that way of coping—how
much pain it’s brought into your
life. It helps with the feelings of de-
fectiveness, but only very briefly,
and then it damages the relation-
ships that really matter to you.
Creative Hopelessness
Once you have worked with clients to assess
the workability of SCBs and establish the re-
lational costs of these behaviors, it’s time to
make a directional shift in treatment and
move into ACT territory: cultivating creative
hopelessness. This is a critical step in ACT.
Creative hopelessness marks the moment
when a client—having recognized the price of
experiential avoidance—considers a new re-
lationship and new response to pain.
Clients begin to recognize that everything
they’ve tried in order to control and
minimize schema-related pain hasn’t worked
and that, if anything, the pain is worse. At
this point, you pose a question that will
shape the remaining treatment process: “If
running from pain and trying to suppress or
avoid it hasn’t worked, could the answer lie
in something quite the opposite? Could it in-
volve not running away? Could the answer
lie in the pain itself? What if letting yourself
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feel the difficult emotions connected to your


schemas was the answer?”
The core message is that the more we try
to avoid schema-related pain, the more we
have that pain. For things to be truly differ-
ent, clients must, in a sense, give up. They
must lose hope that any of their old control
efforts will work in the long run. They must
see that SCBs haven’t worked and will never
work. The false belief that controlling
schema-related pain is possible has simply
been an immobilizing trap.
This is painful, but out of creative hope-
lessness new hope is born—hope that facing
and feeling schema-related pain is possible
and even desirable, in that it might not exact
the terrible toll associated with SCBs. Be-
cause clients take significant risks when they
finally face their schema-related pain, take
your time (a session or two) with developing
the creative hopelessness theme. Until cli-
ents understand and accept the basic ACT
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premise that experiential avoidance (in the


form of SCBs) is the cause of, not the solu-
tion to, interpersonal problems, they will
probably continue their habitual avoidance
strategies. If you’d like to give clients
something to read that explains creative
hopelessness, the Creative Hopelessness
handout may be useful.
Because creative hopelessness can be
such a challenging idea, you may find it use-
ful to have several ways to help clients grasp
this key concept. Metaphors can often be
quite effective in explaining creative hope-
lessness. Here are two that you might
present to clients: the quicksand metaphor
(Hayes & Smith, 2005) and the metaphor of
digging a hole (Hayes et al., 1999).
Struggling in quicksand. The struggle to
suppress schema-related pain, or any painful
emotional experience, can be likened to fall-
ing into quicksand. The more you try to es-
cape, using SCBs or any kind of emotion
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control strategy, the faster you sink. All of


your struggle only gets you more stuck. What
if you were to stop struggling and resisting?
What if you relaxed, fell back, and gently
maneuvered yourself through the quicksand
instead of fighting it?
Digging a hole. Imagine that you’re
trapped in a deep hole. The only tool you
have is a shovel (your old schema coping be-
haviors), and the only solution you know is
to dig. But digging only makes the hole big-
ger and deeper. So you dig into the sides of
the hole, but the edges collapse and the dirt
pours in on you. You try to dig steps, but this
only dislodges more dirt, which also pours in
on you. So what do you do if you’re in a hole
and all you have is a shovel? The first step is
to put the shovel down and stop digging
(stop using old SCBs). Only then can you
find a more workable solution.
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Creative Hopelessness

Feeling stuck and at your wits’ end is an


important moment, because it offers a
lesson that can change your life. Knowing
in your mind and in your heart—with ab-
solute certainty—that the things you’ve
done to manage schema-related pain
don’t work is the first step on a new road.
Admitting and accepting that trying to
stop schema-related pain has only cre-
ated more suffering for yourself and the
people you’re close to creates a paradox-
ical new freedom. Because all of your old
ways haven’t worked and won’t work, you
can choose to do something new.

This is a watershed. It starts with ac-


knowledging that your experience is your
best guide. What does your experience
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with your schemas and schema coping


behaviors tell you? In the long term, do
your coping behaviors work or not? Do
they help you or not? Are they good for
your relationships or not? Take some time
to really consider those questions.

When you answer these questions, the


situation may feel hopeless. Yet there is
hope because there is another way. Hope
starts when you give up all of your old ef-
forts to control schema-related pain. They
haven’t worked, and they won’t work in
the future. In fact, the false belief that
control is possible, that somehow you can
stop the pain, has kept you trapped in a
strategy that doesn’t work.

Your experience tells you that efforts to


control pain aren’t working and that
things only seem to get worse. All of your
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old strategies for coping with schema-re-


lated pain led to a dead end. That’s why
you need to try something new. If run-
ning from pain and trying to suppress or
avoid it hasn’t worked, could the answer
lie in something quite the opposite—in not
running away? Could the answer lie in the
pain itself? What if facing the pain con-
nected to your schemas is the answer?
Stopping the Struggle
How can clients stop the struggle with
schema-related pain? From the ACT point of
view, schema-related pain is as unavoidable
as bad weather. But like bad weather,
schema-related pain comes and goes. It’s
triggered by negative interpersonal events
that cause a surge in schema affect (shame,
fear of loss, hurt, sadness, and so on) and
schema-driven cognitions (“I’m a failure,”
“I’m unlovable,” “I’m not good enough,” “I’ll
never get what I need,” and so on). However,
every day we have dozens of emotions and,
by some estimates, sixty thousand thoughts.
So thoughts and emotions are temporary
events that keep shifting and changing. If cli-
ents can learn to observe and wait, rather
than fight and resist, these private events
will evolve and recede, making way for the
next thought or emotion.
Another metaphor, one that is both
simple and profound, can be very effective
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for helping clients see their experience as


transitory: the metaphor of being the sky,
not the weather. Harris (2009) notes that
this metaphor appears in Buddhist, Taoist,
and Hindu teachings. The sky is always
there, holding the constantly changing
weather. The weather is sometimes cloudy
and dark, sometimes snowy, sometimes
rainy, and sometimes sunny, with a gentle
breeze and fluffy white clouds. While wind,
storms, rain, and sunshine come and go, the
sky remains, receiving each change of weath-
er with perfect willingness. The sky is the
self, holding an endless stream of ever-chan-
ging private events. Here’s an example of
how you might present this metaphor:
Therapist: Having different kinds of weather
is necessary in life. After all, we
wouldn’t take the same delight in a
beautiful sunny day if every day was
bright and blue. Plus, we need rain
and snow to supply water.
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Similarly, we need difficult emo-


tions to let us know when we’re off
course or have lost sight of what’s
important.
Do you think you could observe all of your
weather without struggling with it
or trying to change it? Could you
just observe the sensations in your
body, the thoughts in your head,
and the emotions that surge up and
recede? Sometimes you’re happy,
sometimes sad, sometimes fearful.
Would you be willing to notice all of
your experience as it unfolds, mo-
ment to moment?
Difficult thoughts and emotions, like the
ones triggered by your schemas, are
like a terrible, scary storm with
thunder, lightning, and howling
wind. Eventually the storm quiets
and the air clears. The sky simply
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holds these storms. Could you be


like the sky and stop struggling with
the weather? Could you learn to just
watch it as it comes and goes, just
seeing painful thoughts and feelings
show up and then fade away?
Cultivating Mindfulness
You are proposing radical change to clients
at this point: watching pain without strug-
gling with it; being the steady, clear self that
allows passing thoughts and feelings to have
their moment; and seeing that no matter
how painful these private events are, they are
temporary and are not the self. But how can
clients learn to observe rather than try to
control their experience? Fortunately, hu-
mans have known the answer for several
thousand years: mindfulness.
In this section, you’ll find several exer-
cises to help clients cultivate mindfulness:
Mindful Focusing, the Five Senses exercise,
and mindful activities. Once you’ve taught
Mindful Focusing, ask clients to practice
daily for several weeks until the skill is well
developed, and be sure to check in weekly to
determine how often they’re practicing. We
also recommend starting each session with
about three to five minutes of Mindful
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Focusing to help underscore the importance


of this technique.

Mindful Focusing
The following simple focusing exercise is
an easy way to teach mindfulness in session
and also a good practice to assign for home-
work between sessions. To begin, have cli-
ents observe their breath, all the way from
their nose down to stretching sensations in
their diaphragm. Then have them notice
when private events arrive, labeling them
simply as “thought,” “emotion,” or “sensa-
tion.” If you wish, you can also make an au-
dio recording of the guided practice for cli-
ents to use at home. Here’s a sample script
for a five-minute practice (adapted from
McKay, Davis, & Fanning, 2011):
Therapist: Close your eyes and take a deep
breath, noticing the experience of
breathing. Observe perhaps the
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feeling of coolness as the breath


passes through your nose or
throat… Notice the sensation of
your ribs expanding as the air
enters your lungs… Be aware of
your diaphragm muscle, which sep-
arates the lungs from the abdomen
and is located just below the rib
cage. Feel it stretching with the
breath and relaxing as you exhale.
Just keep watching your breath, letting your
attention move along the path of
flowing air… In and out…in and out.
As you breathe, you will also notice
other experiences. You may be
aware of thoughts. When a thought
comes up, whatever it may be, just
say to yourself, “thought.” Simply
label it for what it is: “thought.” If
you’re aware of a sensation,
whatever it may be, just say, “sensa-
tion,” to yourself. And if you notice
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an emotion, just say to yourself,


“emotion.” Simply label it for what
it is: “emotion.”
Try not to hold on to any experience. Just la-
bel each one and let it go. Then wait
for the next experience. You are
simply watching your mind and
body and labeling thoughts, sensa-
tions, and emotions. If something
feels painful, just note the pain and
remain open to the next thing that
comes up. Keep watching each ex-
perience, whatever it may be, la-
beling it, letting it pass, and noti-
cing what comes next.
Let it all happen while you watch:
thoughts…sensations…feelings. It’s
all just passing weather, while you
are the sky. Just watch…and la-
bel…and let go.
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Let the meditation continue in silence for


another two minutes, then end it by asking
clients to open their eyes and return their at-
tention to the room.
Encourage clients to do this exercise daily
to help them become more comfortable with
and skilled at observing private experiences.

The Five Senses Exercise


Another way to teach observational skills
is to guide clients in sequentially focusing on
each of their five senses. Have them attend
to each for about thirty seconds: hearing,
smelling, seeing, tasting, and touching. Al-
though the whole exercise lasts only two and
a half minutes, in this brief time clients are
encouraged to observe as many experiences
as possible in each modality.

Mindful Activities
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An optional process for increasing clients’


ability to observe their experience is encour-
aging them to engage in mindful activities.
Each week, ask clients to add one more
mindful activity to their repertoire until they
reach a maximum of four to six. Encourage
them to do these mindful activities daily.
Here are some suggested activities:

▪ Mindful dish washing. Notice


all of the sensory experiences of
washing dishes: the warm water,
the slippery soap, the hard edges of
dishes and utensils, the sound of
running water, the smell of the
soap, and so on.

▪ Mindful walking. Notice how


pressure shifts through different
areas of the feet with each step,
how balance shifts, and how the
arms swing. It’s fine to count steps,
but not necessary. Also notice the
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sights, sounds, and smells while


walking. This can be done in the
course of normal daily walking; for
example, to and from work or
school.

▪ Mindful gardening. Notice the


temperature of the soil, the feeling
of resistance while pulling weeds,
the thrust of pushing in a trowel,
the scent of flowers and other ve-
getation, the colors and shapes of
the plants, and so on.

▪ Mindful bathing or shower-


ing. Notice the sound and feel of
the water, the slipperiness of the
soap, the scents of soap and sham-
poo, and the shifting sensations as
water sprays on various parts of
the body.
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▪ Mindful eating. Notice the color


and texture of the food, its temper-
ature, the aromas and flavors, the
sensations of lifting a fork or
spoon, and so on.

▪ Mindful drinking. Notice the


feeling of the liquid in the mouth,
including its temperature and vis-
cosity. Also notice its aromas and
flavors, feelings in the throat and
stomach, the texture and weight of
the glass or cup, and so on.

When engaging in mindful activities, the


goal is to stay with sensory experience. If
thoughts or other private events come up,
they should simply be noted while returning
attention to the five senses.

Working with Resistance to Mindful-


ness Practice
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Because Mindful Focusing operates both


as exposure to painful private events and as
training in observational skills, some clients
will avoid it. This is where you have to en-
courage, cajole, and push clients to practice
this new skill. Here are a few things you can
try with clients who have significant
noncompliance:

▪ Make an audio recording of the


Mindful Focusing exercise and set
a specific time and place for the cli-
ent to practice it each day.

▪ Alternate with less challenging


mindful processes, like the Five
Senses exercise or a simple mind-
ful activity, such as walking or eat-
ing an apple mindfully.

▪ In session, gradually increase the


time devoted to Mindful Focusing
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from five minutes to ten minutes


or even longer.
Observing Interpersonal Experience
Once clients’ mindfulness skills have im-
proved over three or four sessions, begin to
guide them toward observation of interper-
sonal experiences. It’s helpful to begin with a
list of schema triggers so clients can be on
the lookout for these events and remember
to use their observation skills as triggers
arise. We recommend that you first teach cli-
ents to observe schema-related emotions,
thoughts, sensations, and action urges in ses-
sion, using imagery from recent upsetting
events.

Listing Schema Triggers


Begin by listing interpersonal experiences
that the client identifies as schema triggers.
The Interpersonal Triggers Worksheet can
facilitate this process. A sample worksheet
filled out by Maria, a forty-three-year-old
elementary school teacher, follows the blank
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form. Maria, who is divorced and lives with


her thirteen-year-old son, has very active
abandonment and defectiveness schemas.
Maria’s SCBs include aggression or hos-
tility, social withdrawal, and compliance (in
the form of excessive attempts to please her
son), but that isn’t what’s important now.
First, she needs to hone her observational
skills so that she can take note of these trig-
gering interpersonal situations as they occur.
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Observing Schema-Triggering Events


in Day-to-Day Life
In this step of treatment, help clients
make a list of potential interpersonal events
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that could activate their schemas over the


following week, including triggering people
and specific behaviors or events. For Maria,
this might include her weekly call to her
mother, picking up her son on Sunday from
his weekend with her ex-husband, the feed-
back meeting with her principal, and her
son’s criticizing behavior.
In each of the triggering situations listed,
and particularly when clients notice the first
rush of schema affect, the focus should be on
observing inner processes. Encourage clients
to watch the following private experiences:

▪ Noticing schema-based affect:


observing how feelings wax and
wane, and how they sometimes
morph into other feelings (for ex-
ample, hurt into anger)

▪ Noticing schema-relevant
thoughts: observing thoughts
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come and go and trying not to be-


come attached to any of them

▪ Noticing physical sensations:


observing sensations that accom-
pany the interpersonal event, like
feeling flushed or tense

▪ Noticing impulses: noting the


urge to act and somehow avoid the
schema affect—typically urges to
engage in SCBs

▪ Noticing that they have a


choice: realizing that it isn’t ne-
cessary to act on the urge

This last point is the most important


component of the observational experience.
It allows clients to learn that the impulse or
urge to act doesn’t require action. Actual be-
haviors need not be synonymous with the
SCBs clients feel the urge to engage in.
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Encourage them to see the moment when the


impulse enters their awareness and, at that
moment, to recognize they have a genuine
choice about whether to do what the mind
and body urge.
If you wish, you can have clients use the
Interpersonal Experiences Diary to record
their observations during schema-triggering
events.
Over the next three to five weeks, ques-
tion clients about interpersonal events that
triggered schema affect. What did they ob-
serve? When they experienced schema-driv-
en urges, did they choose to act or not? If you
keep encouraging them to use mindfulness
skills to notice these crucial moments, they
will gradually become more skillful at watch-
ing private events. The key is consistent at-
tention so that clients come to expect that
you’ll explore these themes. If you pay atten-
tion to mindfully observing triggering events,
they will too.
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Interpersonal Experi-
ences Diary

Event: ___________
___________
Schema emotions: ___________
___________
Schema-related thoughts:
___________
___________
Physical sensations: ___________
___________
Schema-driven urges: ___________
___________

Circle one: Acted on urges Didn’t act on


urges
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Event: ___________
___________
Schema emotions: ___________
___________
Schema-related thoughts:
___________
___________
Physical sensations: ___________
___________
Schema-driven urges: ___________
___________

Circle one: Acted on urges Didn’t act on


urges

Event: ___________
___________
Schema emotions: ___________
___________
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Schema-related thoughts:
___________
___________
Physical sensations: ___________
___________
Schema-driven urges: ___________
___________

Circle one: Acted on urges Didn’t act on


urges

Practicing Interpersonal Observation


Skills in Session
You can assist clients in learning inter-
personal observational skills in session by
using schema-triggering imagery. Have cli-
ents recall and visualize a recent interper-
sonal event that caused schema affect. En-
courage them to recall visual, auditory, and
kinesthetic aspects of the encounter. Take
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some time to let the emotion build. When


they report significant affect, encourage
them to provide a verbal description of the
event, covering all of the components de-
tailed in the Interpersonal Experiences Di-
ary: emotions, thoughts, sensations, and
urges. Here’s a transcript showing this
process:
Therapist: Try to notice as much as you can
about that moment when your
mother criticized your blouse as cut
too low. Notice where you are, what
the room looks like… Hear all the
sounds: your mother’s voice, any
other sounds in the environment…
Notice how your body feels and
whether you’re touching anything.
Are you there? Are you in the
experience?
Client: Yes. It’s pissing me off all over again!
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Therapist: Even though it’s upsetting, that’s


what we want. Now you have a
chance to just watch the experience.
Okay, so the feeling is anger? Can
you describe it a little more?
Client: I’m humiliated, really. That’s where it
starts. A little girl who’s done the
wrong thing.
Therapist: And the anger shows up as part of
that?
Client: Yes. Ashamed and then angry.
Therapist: Okay, just keep observing your
experience. Are there thoughts that
go with the feeling?
Client: She’s done it to me again. She got me
again. I’ve screwed up.
Therapist: Are there feelings in your body?
Notice what’s happening there.
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Client: I’m hot—in the face. I’m blushing.


Therapist: And what do these feelings make
you want to do? Do they urge you to
some action?
Client: I want to yell at her. I want to just ex-
plode—to scream.
Therapist: Okay. Just watch that. Notice that
it’s just an urge, and that you could
have a choice about whether to fol-
low through.
Client: Well, I’m not going to yell at her in
your office.
Therapist: (Laughs.) Right. You wouldn’t do
it here. But just notice the push in-
side to do it—the drive. Notice that
it’s something you could act on or
not. If you were with your mom,
you could choose to turn that into
behavior, or you could choose not
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to. Or maybe you could choose to


do something completely different.
Client: Yeah. There’s this urge to yell, but
maybe…I don’t have to.
Therapist: Right. So this is what I’m encour-
aging you to observe every time
something happens in one of these
triggering situations. Notice the
emotion—or there may be several
emotions, like this time. Also watch
any thoughts that come up. Try not
to get involved in them or attached
to them. Just notice that the old de-
fectiveness schema is pushing up
some thoughts. Also see if you can
observe any sensations—things
happening in your body. And then
notice any action urges. Watch
them just like you did here, and no-
tice that you have a choice, right in
that moment—that you could turn
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them into action, or you could


choose not to.
Client: (Nods.)
Therapist: This week you’ll undoubtedly
have several opportunities to ob-
serve your schema feelings,
thoughts, and urges. Sometimes
you may get involved in the mo-
ment and forget to observe. But if
you commit to observing your ex-
periences, there’s a good chance
that you’ll be able to notice them
sometimes, watching all of this
weather inside of you, along with
the urges to engage in SCBs. And,
most of all, notice that you have a
choice about whether to act on
them.
Client: I’ll do my best, particularly with my
mother and my son. I don’t like
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what I’m doing in those


relationships.
Therapist: Fair enough. Observe what hap-
pens there.
You may want to repeat this exercise sev-
eral times, particularly for clients who resist
keeping an Interpersonal Experiences Diary
or who don’t notice the moment of choice
and continue to slip into old SCBs.
Summary
The focus of this chapter is teaching clients
to recognize the presence and impact of
schema coping behaviors (in ACT terms, ex-
periential avoidance). Identifying the costs of
SCBs lays the groundwork for creative hope-
lessness. At this stage, clients must confront
the reality that, in the long term, control
strategies have failed. Trying to escape pain
is merely creating more pain and deepening
it into suffering. The key here is to recognize
that doing more of the same can only yield
more of the same. Once clients recognize this
and arrive at creative hopelessness, treat-
ment moves from learning about the prob-
lem to processes for actively changing the
situation. This starts with developing mind-
fulness skills, with an eventual focus on ob-
serving interpersonal interactions. Helping
clients become more aware of schema-trig-
gering events and the related emotions,
thoughts, sensations, and behavioral urges
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will begin to open space for them to make


authentic, values-based choices about how to
respond to schema-related pain.
Chapter 5
Clarifying Values and Committing to
Values-Based Action

As clients become more proficient at ob-


serving schema affect and action urges, the
focus shifts to making changes in patterns of
interpersonal behavior. At this point, clients
should be increasingly noticing the moment
of choice: the point where they can choose
between falling back on old schema coping
behaviors and doing something different.
Together, you and the client are now ready to
address two critical goals:

▪ Creating a plan for behavior


change. The old schema coping
behaviors must stop. But trying not
to do something leaves a behavior-
al vacuum and often fails. So the
ACT approach helps clients devel-
op specific intentions that reflect
their interpersonal values and then
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helps them transform those inten-


tions into committed actions in
relationships.

▪ Developing a values-based ra-


tionale for facing schema-re-
lated pain. In ACT terminology
this is called willingness, and it
hinges on having a reason for fa-
cing and accepting schema-related
pain: so that clients can live and
engage in relationships in a way
that’s based on core values rather
than avoidance (SCBs).

This work begins with clarifying core val-


ues in regard to relationships and then
identifying specific behavioral intentions to
increase values-based living. The next step is
to begin assessing the degree to which clients
are living in accordance with their values.
Through all of this work, contrast committed
action with resorting to old coping behaviors.
Explaining Values
Over the course of a session or two, help cli-
ents identify and clarify their core values in
all relevant interpersonal domains (work,
friends, family, intimate relationships, par-
enting, and community). The goal is to help
clients identify ways of relating that truly
matter to them in each of these areas. This
opens the door to differentiating between
schema coping behaviors and ways of relat-
ing that are based on values. Here’s a sugges-
tion for how to introduce values into the
therapeutic dialogue:
Therapist: All of these schema coping beha-
viors we’ve talked about are having
a big impact on your relationships.
But it doesn’t have to be that way.
There are probably ways you’d
rather be and rather act—ways
based on your values—that could
make relationships feel very
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different. If it’s okay with you, I’d


like to explore what some of your
values regarding relationships
might be. Then maybe we can figure
out what you could do differently if
you brought those values into your
relationships.
Next, define what values are and aren’t,
being sure to distinguish between values and
goals:
Therapist: Your values are a direction you
want to go. They help you figure out
who you want to be and how you
want to act in each domain of your
life. Here’s an example: If someone
says, “I want to be the kind of friend
who is there for people, who listens
and helps and is always on their
side,” that’s a value. It sets a course
in relationships in the realm of
friendship. A value indicates where
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a person wants to go and how the


person wants to be.
A value is different from a goal. A goal might
be to help a friend fix his car or give
him a ride to the airport. Unlike val-
ues, those are specific actions that
you can finish. You can say, “I ac-
complished that.” But a value is a
way of living that matters to you. In
relationships, it’s a way of being
with people. You never
“accomplish” a value; you just keep
going in that direction.
I’d like to spend a little time exploring some
of your values in relationships.
Would that be okay with you?
When you introduce and define the
concept of values, be sure to indicate that
values are personal, not dictated by social
norms, other people’s expectations, or even
what clients think they should value. In ACT,
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the definition of values includes the phrase


“freely chosen” to reflect this key quality of
authentic values.
Clarifying Interpersonal Values and
Intentions
Now it’s time to get specific. Explore the six
domains of interpersonal relationships and,
for each that is salient to the client’s life,
work collaboratively to identify at least one
interpersonal value. In this chapter, we’ll use
examples involving a client named Rebecca,
a thirty-five-year-old woman who struggles
with failure and mistrust schemas. The dia-
logue might begin like this:
Therapist: Rebecca, when you think about
your work relationships, are there
some guiding principles for how
you’d like to be and act with work
colleagues, or even your
supervisors?
Rebecca: I don’t know.
Therapist: Okay. I’m wondering what sort of
person you want to be with
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colleagues or bosses. Maybe it’s dif-


ferent for each; I don’t know. But
think about how, if you acted on
your values, you would be in those
relationships.
Rebecca: I guess I’d want to give honest feed-
back about what we’re doing but
not be mean or critical, like I can
be. Just say what needs to be done,
in a supportive way.
Therapist: Okay. You want to tell a support-
ive version of the truth about what’s
going on with tasks and projects.
Anything else?
Rebecca: I think I’d like to support my
coworkers’ initiatives and creative
ideas—not be full of judgments and
criticisms.
You can do this process in session and re-
cord the client’s responses on the Valued
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Intentions Worksheet. An alternative is to


assign the worksheet as homework and dis-
cuss the values the client identifies in the
next session.
When using the worksheet, whether as
homework or to structure a discussion, have
clients assign a rating of importance to each
domain using a scale of 0 to 2, where 0
means not important, 1 means moderately
important, and 2 means very important. For
any domain rated above 0, clients should
identify one or two key values in regard to
relationships in that domain. Values can of-
ten be stated as general principles and usu-
ally indicate a way of being; for example, be-
ing honest, being open, or being supportive.
The next step is to convert these general
values into specific behavioral intentions.
For example, how, exactly, would a client
turn the parenting value “giving my children
the experience of being loved” into action?
Specific intentions might include “spending
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time each evening finding out what their day


was like” or “using validation rather than an-
ger while setting limits.” Generating specific
intentions allows clients to develop a tar-
geted plan for behavioral change based on
their values.
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Contrasting Values-Based Behaviors with
SCBs
As you help clients map their values, it’s use-
ful to draw a contrast between schema cop-
ing behaviors and behavior based on inter-
personal values. Start by identifying an SCB
that shows up in a specific domain. Then ask
clients to explore differences between the
SCB and how they would act in that relation-
ship and situation based on their values.
Here’s an example dialogue with Rebecca:
Therapist: I know that old failure schema
gets triggered by your boyfriend.
When you feel you’re not doing it
right, not living up to what he ex-
pects, you get drawn into schema
coping behaviors—usually with-
drawal or being critical. How do
your values about this relationship
contrast with those old coping
behaviors?
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Rebecca: I want to validate and appreciate


him rather than criticize him.
Therapist: What about the old failure
feelings?
Rebecca: I know. That’s why I criticize. I try
to make it seem like he’s got a prob-
lem, not me.
Therapist: So how is your new intention go-
ing to change that?
Rebecca: I want to focus on what’s really
great about him and tell him that,
not all the critical stuff.
Cultivating Willingness to Accept Schema
Affect
The good news is that values-based inten-
tions regarding relationships can often re-
place problematic SCBs. But the bad news is
that clients must be willing to accept painful
schema affect. Acting on values rather than
running away from schema-related pain
means clients must look at and face that
pain. They have to be with feelings of defect-
iveness, deprivation, failure, or whatever
schema-related affect shows up. And at this
point, clients haven’t learned all of the ACT
processes that will help them face this pain.
Still, you do need to clearly acknowledge that
this is the task. Here’s a dialogue outlining
how you might do so:
Therapist: When you stop criticizing and in-
stead say out loud the things you
appreciate about your boyfriend,
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what’s going to happen with the old


failure feeling?
Rebecca: I don’t know—it will probably be
worse.
Therapist: Why?
Rebecca: Because when I’m not focused on
his screwups, I’ll fall back into my
crap.
Therapist: Could I ask you this: Would you
be willing to feel that when it comes
up—the old failure pain—so you
could act on your values in this rela-
tionship? Could you experience
those painful feelings so that you
can validate and appreciate your
boyfriend?
Rebecca: That’s what I want to do. But that
failure stuff is like a screaming
banshee.
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Therapist: I know. It’s a hard choice.


Rebecca: (Nods.) I do want to change this.
Assessing Values-Based Living
Once you’ve identified clients’ interpersonal
values, you can begin measuring how effect-
ively they stay on course week by week. The
simplest way to do this is to review actions in
each domain using a values compass.
A values compass is made by drawing a
circle and putting a dot in the middle of it.
Where north would appear at the top of a
compass, write a V, for values. Have clients
rate how much or little their behavior over
the past week reflected their values in each
domain by drawing an arrow from the dot in
the middle of the compass to a point on the
circle. The closer the arrow points to the V,
the more their behavior matched their values
in this domain. Conversely, the farther from
the V—at worst pointing straight down—the
less their behavior was aligned with their key
values.
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An alternative to the compass is to simply


rate each week’s adherence to values in each
domain on a scale of 0 to 10, where 0 indic-
ates no values-based behavior and 10 means
that essentially all behavior in that domain
was values-based.
An easy way to set up either assessment
is using multiple copies of the list of six do-
mains. As you discuss clients’ efforts to align
their interpersonal behavior with their val-
ues over the previous week, you can use the
scale of 0 to 10 to indicate the degree of
values-based behavior. Alternatively, you can
draw a circle for a values compass next to
each domain and have clients draw in an ar-
row to indicate degree of compliance. Either
way, the assessment can lead to a discussion
about barriers to values-based action in cer-
tain domains.
Using Commitment to Overcome Barriers
Encourage clients to regard their intentions
as commitments—commitments to them-
selves to do what matters, to be who they
want to be in relationships. A commitment
to one’s values is no less sacred than a prom-
ise to a loved one. In essence, it means say-
ing, “I will do this because it’s important, be-
cause old schema coping behaviors are dam-
aging my relationships, and because there’s
another way to live.”
Emphasize how effective formal commit-
ments can be in motivating and assuring be-
havioral change. Also emphasize that com-
mitments—particularly commitments to
values-based behavior—often run into barri-
ers. Validate how hard this is.
It’s worthwhile to review these commit-
ments during most sessions. Have any of the
intentions changed? Did specific barriers to
values-based behavior arise? Are clients
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willing to renew their commitment to key in-


tentions out loud with the therapist? Remind
clients that making a commitment in this
way, formally and in public, increases its
power and the likelihood of following
through.
Here’s an example dialogue where the
therapist helps Rebecca review and renew
her commitment to values-based behavior in
her relationship with her boyfriend:
Therapist: Rebecca, this turned out to be a
hard week with your boyfriend. He
complained about your work sched-
ule, and that set off feelings of fail-
ure. And then you slipped into criti-
cizing to try to protect yourself from
that pain. I understand.
Rebecca: I was on him for all this little stuff.
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Therapist: And the arrow you put on the val-


ues compass is pretty close to
straight down.
Rebecca: Yeah. I kind of lost my way last
week.
Therapist: Okay, that was last week. The fail-
ure feeling really got to you. But
this is a new week, a fresh start.
And even though some of that old
pain might show up, do you want to
recommit to your intention to valid-
ate and appreciate rather than
criticize?
Rebecca: Yes, that’s what I want.
Rebecca is struggling with significant
barriers to her commitment. There are emo-
tional barriers, such as her sense of failure
and incompetence in the relationship. At one
point, Rebecca said, “I feel like a relationship
idiot.” There are also cognitive barriers:
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negative self-labeling and thoughts about


past relational failures. In addition, there are
behavioral barriers. Rebecca wonders wheth-
er she even knows how to show appreciation
or give praise. In her words, “It sounds stu-
pid and contrived when I say stuff like that.”
This is a critical point in treatment. Cli-
ents have to acknowledge and face these bar-
riers while also maintaining a commitment
to their values and intentions in
relationships.

Labeling Barriers
The first step in dealing with barriers is to
label what they are. The mere act of describ-
ing the obstacles to values-based behavior
can make them seem less overwhelming. To
do this, use the Assessing Barriers Work-
sheet to help clients identify specific emo-
tional and cognitive barriers that are likely to
show up for each values-based intention.
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Take your time with this important step, de-


voting at least one session to exploring
barriers.
The emotional barriers to values-based
action in relationships are usually schema af-
fect: fear of rejection, abandonment, hurt, or
failure, plus shame, emotional hunger, and
anger. These have usually already been
named as you explored schema-related pain
and its impacts on relationships. The cognit-
ive barriers are schema-relevant thoughts
that predict rejection, abandonment, hurt, or
failure. They also show up as cognitions
about past losses, failures, and so on and
negative judgments about oneself and oth-
ers. These thoughts serve to intensify both
schema affect and SCBs.
Behavioral barriers, which aren’t on the
worksheet and are beyond the scope of this
book, include skill deficits (for example,
lacking key interpersonal skills) and
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logistical problems, such as physical dis-


tance, financial costs, or time constraints.

Facing Barriers
As clients move toward values-based in-
terpersonal behavior, emotional and cognit-
ive barriers are likely to emerge. An excellent
way to recognize and work with them is
through the monsters on the bus metaphor
(Hayes & Smith, 2005). Hold this metaphor
in reserve for exploring a value or intention
of great importance to clients, then devote
about half a session to developing the meta-
phor. It provides a powerful explication of
the key ACT concept that avoiding
uncontrollable schema-related pain results
in dysfunctional and damaged relationships,
whereas willingly facing and accepting the
pain opens the door to creating functional
relationships based on core interpersonal
values.
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To begin, ask clients to focus on one im-


portant relational value. Then suggest that
living and directing one’s life is analogous to
driving a bus. As clients steer the bus (their
life) toward a key value, certain monsters
(barriers) show up to block the way. There
are emotional monsters (schema affect) and
cognitive monsters (schema-driven
thoughts). Here’s a sample dialogue with Re-
becca that shows how to engage clients in
this metaphor:
Therapist: Okay, Rebecca. Let’s imagine that
you’re driving your bus, which
means steering your life, toward
your value of being honest and sup-
portive with your coworkers. That
value is up ahead, and you’re driv-
ing toward it. What specifically will
you do as you turn that value into
action?
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Rebecca: I’m going to state my concerns


about the new software, but I’m go-
ing to do it gently, not harshly. My
usual mode is to go on the at-
tack—kind of snipe and exaggerate
problems so I can look super-com-
petent. And when people have
good, creative ideas, I’m going to
support them, even if it makes me
look less smart or like I’m not doing
that great of a job. Often I kind of
snipe at people’s ideas.
Therapist: Because their good ideas set off
that failure feeling.
Rebecca: Yes.
Therapist: So you’re driving your bus toward
these values, and I guess we can
already see one of the monsters that
jumps up in front of you. That fail-
ure feeling—the fear that you’re not
as smart or not doing as good a job.
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Rebecca: Right. It’s a big, ugly one.


Therapist: Are there other emotional
monsters?
Rebecca: Yeah. The feeling that I can’t trust
these people—that they’ll climb up
on top of me to get ahead. I’m
afraid they’ll make me look stupid
or like I’m not contributing.
Therapist: So you have a feeling of distrust,
fearing that colleagues might hurt
you. Anything else?
Rebecca: A fear that I’m going to lose my job.
Therapist: What about those mental mon-
sters—the scary or painful
thoughts?
Rebecca: Like I just said, the thought that
they’ll lay me off. I also have this
judgment about myself—that I’m
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not that smart or capable and that


I’ll be exposed.
Therapist: Anything else? Imagine that
you’re acting on your value at work:
being supportive and gentle, not
harsh.
Rebecca: Here’s a monster: the thought that
some of them don’t like me and are
waiting to screw me.
Therapist: Okay, so the emotion monsters
and the mental monsters are all
jumping up and down in front of
your bus. They’re trying to stop you.
What happens if they make you
stop or force you to steer in another
direction?
Rebecca: I go back to my old crap.
Therapist: The old schema coping behaviors:
sniping, criticizing, and attacking.
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Rebecca: (Nods.)
Therapist: What happens then?
Rebecca: I screw up my relationships at
work. I get isolated and angry. This
has happened at other jobs.
Therapist: Okay. That doesn’t work. You’ve
gone that direction with your bus
before and bad things happened.
But the monsters are still jumping
up and down, blocking your way.
What are you going to do?
At this point, let clients struggle to figure
this out. After you’ve given clients some time
with this conundrum—that experiential
avoidance and SCBs don’t work but the bar-
riers are formidable—reveal the solution:
The answer is to let the monsters on the bus
and keep driving in a valued direction.
Therapist: What if you opened the bus door?
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Rebecca: And let them on?


Therapist: Right. Let all the monsters take
seats behind you on the bus—all of
them jumping up and down and
screaming, “You’ll be a failure,”
“You’ll be fired,” “People don’t like
you,” “They’ll hurt you,” and on and
on. What if you just take them with
you, along with all of their cater-
wauling, while you drive in the dir-
ection of your values?
Rebecca: It’s hard even just listening to that.
Therapist: Right, but if you take them with
you, you can go where you want to
go. You’re free to move and be the
person you want to be.
This metaphor can be a touchstone
throughout treatment. It highlights the key
choice in ACT: avoidance versus facing and
feeling the pain while living one’s values. The
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barriers (monsters) will always show up, but


clients don’t have to let those obstacles con-
trol their behavior.
Here’s a recap of the steps for developing
the monsters on the bus metaphor:

1. Introduce the basic metaphor, in


which navigating through life and
moving in the direction of values is
imagined as driving a bus.

2. Focus on specific values-based be-


haviors (intentions) in a particular
domain. Have clients take some
time to describe and visualize this
behavior.

3. Encourage clients to identify emo-


tional and cognitive barriers (mon-
sters) that may come up as they en-
gage in the new behavior.
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4. Explore the outcome of avoidance


and SCBs: steering the bus away
from the monsters—and away from
their values.

5. Explore how clients can move to-


ward their values with the
monsters.
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Awareness with Willingness
It’s important to continue to encourage cli-
ents to mindfully observe interpersonal
events. In the earlier work, clients began to
observe interpersonal interactions that
triggered their schemas and used the Inter-
personal Experiences Diary to record their
schema-related emotions, thoughts, physical
sensations, and behavioral urges.
Now these same observational skills are
applied to situations where clients are acting
on their values. Because values-based inter-
personal behavior frequently entails facing
barriers (schema affect and cognitions), this
is exactly the time to encourage mindful
awareness. In addition to watching their cog-
nitive and emotional barriers to valued liv-
ing, clients can also observe their willingness
to face this pain. You can use the Awareness
and Willingness handout to guide clients in
mindfully observing their experience. You
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can also give them the handout and even as-


sign this practice as homework.

Awareness and
Willingness

Whenever you choose to act on your val-


ues, watch what happens:

Observe and mentally label emotion-


al barriers that make you want to
avoid taking valued action; for ex-
ample, fear, shame, sadness, or
anger.

Observe mental barriers; for ex-


ample, thoughts of danger or attacks
on or judgments about yourself or
others.
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Observe impulses to act. What urges


to engage in old coping behaviors do
you experience?

As much as possible, hold on to a willing-


ness to experience whatever thoughts
and feelings arise while acting on your
values.

If you want, you can write these observa-


tions down, or you can simply keep them
in mind for the next session.

In the Interpersonal Experiences Diary in


chapter 4, each entry ended with the ques-
tion of whether clients acted on urges to en-
gage in SCBs. In addition, they were encour-
aged to make the choice of whether to do so
mindfully. Now there’s a new question: Can
clients be willing to face and experience
these monsters—to bring them on the bus so
they can continue moving in the direction of
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their values in relationships? Notice that


we’re using the word “willing” again. That’s
because this is essentially an exposure exer-
cise. Clients are asked to experience and
observe schema-related pain, however it
shows up and for as long as it lasts. They’re
encouraged to stay with it, to be willing to
have these painful cognitive and emotional
experiences without running away. Why? So
that they can act based on their values in re-
lationships, even though that often brings
pain. Here’s another example dialogue with
Rebecca that focuses on this issue:
Therapist: So this week’s intention with your
boyfriend is to validate something
you appreciate about him each
day—and to do this instead of com-
plaining, which sometimes protects
you a little from the failure feelings.
Would you also observe what hap-
pens when you praise him and af-
terward use your mindfulness skills
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to see what feelings and thoughts


come up?
Rebecca: I’ll do my best.
Therapist: Remember willingness? Would
you be willing to let the monsters
on the bus—let them chatter and
say all of their painful stuff, and still
act on that commitment to be sup-
portive with your boyfriend?
Rebecca: (Long pause.) I’ll let the failure
stuff on the bus. But I don’t know
how long I can keep it there. Okay?
Therapist: Just keep watching and see what
happens.
Awareness with willingness returns to
two themes that run throughout treatment:

▪ Mindful awareness allows clients


to observe their experience and
make conscious choices.
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▪ In the face of painful affective and


cognitive barriers, clients can
choose to engage in either avoid-
ance or willingness. Willingness to
be with whatever there is to experi-
ence creates the foundation for
values-based behavior.

You should touch on these themes in


most of the remaining sessions. Also, note
that mindful awareness of experience is a
form of exposure. Throughout treatment, fa-
cilitating exposure to emotional and cognit-
ive barriers, while also encouraging willing-
ness, will anchor the therapy process.
Summary
This phase of the work focuses on identifying
core relational values, identifying specific be-
havioral intentions, and measuring clients’
adherence to values—and, throughout this
process, contrasting clients’ values-based in-
tentions with old coping behaviors. Once val-
ued intentions are identified, the focus shifts
to helping clients distinguish between
values-based behaviors and old ways of cop-
ing, while also continuing to help them see
the costs of avoidance and the benefits of
willingness, even in the face of challenging
barriers. This is the key to commitment and
therefore the key to overcoming barriers.
The monsters on the bus metaphor can be a
powerful way of reinforcing this concept, set-
ting the stage for developing awareness with
willingness. This returns the focus to themes
that have great relevance to the remainder of
the treatment: observing one’s experience
and making conscious choices, and choosing
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values-based behavior in spite of barriers


and schema-related pain.
Chapter 6
Defusing from Thoughts and Developing the
Observer-Self Perspective

The work in the previous chapter firmly es-


tablished the ACT formulation that efforts to
avoid uncontrollable pain (including
schema-related cognitive barriers) only res-
ult in secondary pain, or suffering. This
provides crucial motivation for clients to
abandon avoidance in favor of their values.
As they do so, however, schema-driven
thoughts tend to show up in a big way, so
now the focus shifts to cognitive barriers.
Here are some typical examples:

▪ This won’t work. I can’t do this.

▪ Others will see how screwed up I


am.

▪ I’ll be rejected or left.


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▪ Others will hurt me.

▪ I can’t do anything right.

▪ If I’m honest, others will be


disgusted.

Schema-driven thoughts tend to fall into


three categories: predictions of rejection,
hurt, or failure; memories of past losses or
failures; and negative judgments about one-
self or others. The cumulative effect of these
cognitions is pressure to return to old,
familiar schema-driven behaviors: attack,
surrender, or avoidance. If clients are to
make real changes in how they relate, they
need new resources to deal with these pain-
ful and discouraging thoughts.
Building Awareness of Thoughts
In order to respond differently to schema-
driven cognitions, clients must first notice
them and begin to understand how they
work. Explain that thoughts occur spontan-
eously and that we have little control over
their frequency or content—that they’re go-
ing to show up whether we like it or not.
Schema-driven thoughts are likely to arise
whenever clients attempt to engage in new,
values-based behavior—and in response to
any schema-relevant interpersonal event.
For example, if a client who struggles with an
abandonment and instability schema experi-
ences the slightest hint of rejection, thoughts
predicting loss and abandonment will almost
certainly come up.
Explaining this concept shouldn’t take
long. You can accomplish it in a few minutes
using a couple of helpful metaphors: the
popcorn machine metaphor and the tug-of-
war metaphor (Hayes et al., 1999).
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The popcorn machine metaphor.


Suggest that the mind is a popcorn machine
that keeps popping up thoughts eternally.
Nothing can turn it off. Pop after pop, kernel
after kernel, the mind continues generating
thoughts. Emphasize that blocking or stop-
ping these thoughts isn’t an option. The
mind is a machine that keeps creating
whatever thoughts it likes, whenever it likes.
The tug-of-war metaphor. Suggest that
trying to resist or argue with schema-driven
thoughts is like getting into a tug-of-war with
your mind. The more you struggle and try to
get rid of or refute a thought, the harder the
mind pulls on the other end of the rope. It
can always cook up more judgments, predic-
tions, and negative memories. The only way
out is to drop the rope and stop trying to
control the mind. Encourage clients to let
thoughts come and go, even those that are
painful and disturbing. Every effort at
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control is just picking up the rope and re-


turning to that tug-of-war.
Not Buying Into Thoughts
When painful thoughts occur, clients need to
know that, once again, they do have a choice
about how to respond. They can attempt to
suppress the thought, they can buy into the
thought, or they can simply notice it and let
it go. The first two strategies simply aren’t
workable. As the tug-of-war metaphor indic-
ates, and as research has proven (Wegner,
1989), attempting to suppress or block
thoughts doesn’t work. And buying into
thoughts—taking them seriously and accept-
ing them as true—can lead to cognitive
chaining, where one negative thought begets
another in long, thematically related
sequences.
You might take up to half a session to
cover this material, perhaps using the meta-
phor of a sales representative to explain why
it isn’t a good idea to buy into thoughts
(Vuille, 2006a):
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Therapist: Picture your thoughts as sales


representatives. If you don’t express
interest, some of them go away
quietly; they aren’t very insistent.
But then there are the pushy
salespeople. They’ll hang around
and keep popping up, trying to en-
tice you with a suitcase full of
products. If you say okay and give
them your attention, before long
the suitcase is open and stuff is
spread out all over your living
room. If you go for one product,
suddenly the salesperson has a
bunch of other things to sell you.
Some thoughts, like the hardcore sales rep,
are very compelling, and they keep
coming back to bother you. But as
soon as you take them seriously and
give them a lot of attention, or buy
into them, you’ll get bombarded
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with another related thought, and


then another, and then another.
Remember the monsters on the bus and the
thought monsters you encountered?
Which of the thought monsters con-
nected to your schemas are really
good sales reps? Which of those
thoughts do you tend to buy into?
Go ahead and list a few of them for
me now.
This metaphor is getting at two key con-
cepts: First, some thoughts are more compel-
ling than others. It’s relatively easy to let go
of thoughts that aren’t relevant to painful
schemas. But it’s tempting to buy into
charged, schema-related thoughts, opening
the door to the chaining effect. Second, buy-
ing into thoughts is a choice. It doesn’t have
to be an automatic response when a compel-
ling thought shows up, but it’s much more
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likely when clients give thoughts significant


attention and serious consideration.
So if suppressing thoughts and buying in-
to them only makes them stronger and more
disturbing, what else can clients do? They
can choose the third option: simply noticing
thoughts and then letting them go. This
more effective response to schema-driven
thoughts is the ACT process known as cog-
nitive defusion.
Cognitive Defusion
Cognitive defusion has its roots in the
Buddhist practice of observing and distan-
cing from thoughts (Hayes et al., 1999). ACT
offers a wide array of defusion techniques, all
with the effect of changing one’s relationship
to the mind. Observing thoughts and then la-
beling and releasing them facilitates detach-
ment, or defusion. As a result, the thoughts
are given less attention and are taken less
seriously. As clients learn defusion, they find
that instead of being a thought (for example,
“I’m selfish” or “I’m unlovable”), they can
simply have the thought (“I’m having a
thought that I’m selfish” or “I’m having a
thought that I’m unlovable”). Being a
thought makes a thought seem absolutely
true. Clients gets fused to it and stuck with it.
Having a thought promotes the understand-
ing that it’s just a thought, one of tens of
thousands each day.
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Cognitive defusion has four component


skills: watching thoughts, labeling thoughts,
letting go of thoughts, and distancing from
thoughts. In this chapter, we’ll offer a variety
of exercises and thought experiments (all ad-
apted from McKay et al., 2011, and some
based on Hayes et al., 1999) to help clients
develop each component skill.
Fusion with thoughts tends to be very
deeply ingrained, arising as a result of our
earliest learning about language and com-
munication. Therefore defusion can be a
challenge. Take two to three sessions to
guide clients through all four components of
defusion sequentially. The first week assign
homework of a daily watching exercise, the
second week assign homework of a daily la-
beling and letting go exercise, and the third
week have clients experiment with various
distancing techniques daily.
One final note before we get into specific
defusion techniques: In practice, ACT
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therapists frequently work on schema-driven


thoughts and emotions at the same time,
merging defusion with emotion exposure.
However, we’ll cover exposure to emotions in
the next chapter, presenting the two tech-
niques sequentially for greater clarity. This
isn’t meant to imply that these approaches
should be implemented sequentially in
therapy.

Watching Thoughts
The starting point of defusion is learning
how to watch the mind. There are several ef-
fective methods for teaching this. In this pro-
tocol, we use Mindful Focusing (see chapter
5) and the White Room Meditation. As you
introduce defusion, we recommend that you
start with the White Room Meditation.

THE WHITE ROOM MEDITATION


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The White Room Meditation is an eyes-


closed practice in which clients imagine their
mind as a white room through which their
thoughts pass. You can either describe key
elements of the practice or read the following
script:
Therapist: Imagine that you’re in a white
room, completely empty of fur-
niture or any adornments. You can
position yourself anywhere in the
room: at the ceiling, on the floor, in
one of the corners—wherever you
like. But wherever you put yourself,
visualize an open doorway on your
left and a second open doorway to
your right. The doors open onto
darkness; you can’t see anything
beyond.
Now imagine that your thoughts are entering
from the doorway on your left,
passing across your field of vision,
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and exiting through the doorway on


your right. As your thoughts cross
the room, you can attach them to a
visual image—a bird flying, an an-
imal running, a hulking mafioso, a
balloon, a cloud, or anything else.
Or you can simply say the word
“thought” to yourself. Don’t analyze
or explore your thoughts. Allow
each to have a brief moment in your
awareness and then exit through
the doorway to your right.
Some thoughts may feel urgent or compel-
ling. Some may want to stick
around longer than others. Just let
each one move on out the door to
make room for the next thought. As
new thoughts show up, make sure
you’ve relinquished the old ones,
but don’t worry if they show up
again. Lots of thoughts tend to re-
peat themselves, and the visitors to
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your white room may be no


exception.
After the meditation, discuss with clients
whether their pace of thinking changed, how
easy or difficult it was to let go of thoughts,
and the relative urgency of various thoughts.

MINDFUL FOCUSING
Once clients have explored the first pro-
cess for watching thoughts (the White Room
Meditation), revisit Mindful Focusing, from
chapter 5. Guide clients in Mindful Focusing
for four to five minutes, encouraging them
not to pay a lot of attention to the thoughts.
Ask them to simply label each one (“There’s
a thought”) and then observe their breath
until a new thought shows up. For at least
two weeks, give clients a homework assign-
ment of doing five minutes of Mindful Fo-
cusing each day. As they get more experience
observing cognitive processes, discuss
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whether they are experiencing any changes


in their relationship to thoughts. Is there any
shift in terms of intensity, believability, or
intrusiveness?

Labeling Thoughts
Building on observing thoughts, the defu-
sion skill of labeling thoughts emphasizes
that cognitions are products of the mind
(Hayes et al., 1999). They aren’t real or a pri-
ori truths. They are just thoughts.
In ACT, a key approach to thought la-
beling is to teach clients the phrase “I’m hav-
ing the thought that ___________ .” Here
are some examples: “I’m having the thought
that Linda will leave me.” “I’m having the
thought that I can’t be honest.” “I’m having
the thought Bill is distant because he sees
how screwed up I am.”
Alternatively, clients can use the phrase
“Now my mind is having a ___________
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thought.” Labels you could recommend for


this exercise might include “fear” thought,
“judgment” thought, “should” thought, “I’m
bad” thought, “why” thought (explaining why
something happened), and so on. Work col-
laboratively with clients to develop labels
that reflect their use of language and their
schema beliefs.
Next, have clients observe a sequence of
thoughts, labeling each as it comes up: “Now
my mind is having an ‘I’m bad’ thought…
Now my mind is having a ‘she’s bad’
thought… Now my mind is having a ‘fear’
thought… Now my mind is having another
‘fear’ thought… Now my mind is having a
‘why’ thought,” and so on.
Whenever clients express schema-driven
thoughts, help them label the cognition as of-
ten as possible. Here’s an example dialogue:
Client: I realize when my girlfriend tells me
how I don’t talk about my feelings
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that she’s trying to make me feel


bad about myself—trying to make
me feel wrong.
Therapist: Is that thought familiar?
Client: Yes.
Therapist: Does it connect to any of the
schemas we’ve talked about?
Client: (Long pause.) Defectiveness, I guess.
That’s how it makes me feel,
anyway.
Therapist: What happens if you just label the
thought: “I’m having the thought
that…”? Could you try that?
Client: I’m having the thought that she wants
to make me feel bad.
Therapist: What do you notice when you la-
bel it?
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Client: It sounds weird, like it’s a little


ridiculous.
Therapist: Yeah, like it’s just a thought…not
quite as serious. Remember those
other labels we came up with, like
“judgment” thought and “fear”
thought? What sort of thought is
this?
Client: I guess it’s a “why” thought. I’m try-
ing to figure out why she tells me
that.
Therapist: What do you notice now about the
thought?
Client: It feels farther away, not as big a deal.
Next, the therapist confronts the problem
of getting the client to use this process on his
own:
Therapist: How could you remember to do
this when you’re not in here—for
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example, when something comes up


between you and your girlfriend?
Client: (Long pause.) I guess when I’m
upset…
Therapist: That could be a cue. What could
you do when you’re upset?
Client: I could see what my mind is do-
ing—notice my thoughts.
Therapist: Okay, and what could you do
then?
Client: Just say, “My mind is having a ‘such
and such’ thought.”

Letting Go of Thoughts
Once clients have practiced observing
and labeling thoughts, you can teach them a
variety of techniques to help release thoughts
and let them go. Recommend that they
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experiment with several of the following ex-


ercises to see which are most effective for
them.
Leaves on a stream. Encourage clients to
imagine each thought as an autumn leaf fall-
ing from a tree and landing on the surface of
a swiftly moving stream. As each leaf hits the
water, it gets swept into the current and dis-
appears around a bend downstream. With
each new thought, clients should visualize
the same set of images.
Billboards. Have clients imagine driving
down a long stretch of highway. As each
thought shows up, it appears on a billboard
ahead. Encourage clients to briefly note the
thought and then imagine their car sweeping
past.
Balloons or clouds. Have clients visualize
a clown holding the strings to a dozen heli-
um balloons. As each new thought arrives, a
balloon detaches and floats away on the
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wind. Alternatively, have clients visualize a


blue sky with occasional clouds passing over-
head. They can put each thought on a cloud
and let it drift away.
Computer pop-ups. Have clients imagine
each thought as a pop-up advertisement or
reminder on a computer screen. They can
briefly take note of each thought and then let
it disappear until the next pop-up appears.
Trains or boats. Have clients imagine a
railroad crossing with a slow freight train
grinding past. Each new thought is yet an-
other boxcar rolling by. Alternatively, have
them visualize fishing boats passing beneath
a bridge one by one, with each boat carrying
a single thought out of sight.
Physically letting go. Whereas all of the
previous letting-go exercises are based solely
in imagery, this one is somewhat physical.
We encourage you to practice this exercise
together with clients. Have clients hold out
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their right hand, palm up, as you do the


same. As each thought arrives, imagine
briefly holding it in your hand. Then rotate
your hand so your palm is facing down and
imagine the thought dropping down and out
of sight. Then return your hand to the palm-
up position to receive the next thought. Keep
dropping thoughts each time they show up.
Making the letting-go process physical helps
it feel more powerful and real.

Combining Watching, Labeling, and


Letting Go
Once clients understand the first three
components of defusion—watching, labeling,
and letting go—they can put them together in
a single process. The easiest way to accom-
plish this is to have clients choose one la-
beling technique and combine it with one of
the letting-go visualizations or the physical
letting-go technique. We recommend that
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you have the client choose and then practice


together. This allows you to both model the
behavior and encourage a bit of risk taking
as both of you reveal the frequency, if not the
content, of thoughts. Here’s a sample
dialogue:
Therapist: Okay, let’s see if we can put la-
beling and letting go together.
Which labeling strategy do you
want to use?
Client: I like “I’m having the thought that…”
Therapist: Fine. And letting go—do you want
to use a visualization or drop the
thought from your hand?
Client: Drop it from the hand.
Therapist: Okay, let’s do it together. As soon
as either of us has a thought, we’ll
say to ourselves, “I’m having the
thought that…” And then we’ll turn
our hands to drop it. (Therapist
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and client randomly turn their


hands as they drop thoughts.)
If the client chooses a visual letting-go
strategy, there won’t be any outward indica-
tion of a passing thought. In this case, keep a
running tally, out loud, as you each let go of
thoughts. Continue the exercise until one of
you reaches about twenty thoughts.
Some clients prefer physically letting go
by turning their hand but are embarrassed
about doing so in public. To deal with this,
suggest more subtle movements, such as a
slight spreading of the fingers, a gentle lifting
of the fingers as if waving good-bye, and so
on.
Encourage clients to practice labeling and
letting go daily at specific times. When the
time comes, it doesn’t matter whether their
thoughts are troubling. It’s important that
they master this defusion technique, and re-
hearsing at times when they aren’t distressed
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will help them remember to use defusion


when difficult, schema-driven thoughts show
up. Also practice the technique in session as
salient situations arise:
Therapist: Can you just label that thought
and let it go?
Client: Right now?
Therapist: Yes.
Client: My mind is having a “fear” thought.
(Pauses.) Okay, I put it on a leaf.
Therapist: Now what do you notice?
Client: I’ve sort of moved on from it.
Therapist: If it comes up again, could you say
so and do the same thing—just label
and let it go?

Distancing from Thoughts


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Certain defusion exercises are especially


effective for creating space between the self
and the thought. Practicing these techniques
helps clients learn to take cognitions less ser-
iously. Distancing processes have a common
element: They embrace a painful thought
while, paradoxically, allowing it to diminish
in importance. Here are several distancing
exercises. Encourage clients to experiment
with all of them to see which techniques are
most effective for them.

THANK YOU, MIND


Explain to clients that the mind is always
trying to help them survive. It’s constantly
working to protect them from danger, make
judgments about what’s good or bad for
them, or explain why things happen. But
sometimes the mind goes overboard, finding
danger when there isn’t any, making painful
negative judgments, or explaining things in
such a way that clients feel ashamed or
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wrong. One way to respond to these thoughts


is to thank the mind for its efforts. As each
painful, schema-driven thought shows up,
encourage clients to use the mantra “Thank
you, Mind, for that thought,” and then let it
go.
This exercise can be done as a long se-
quence of thank-yous: “Thank you, Mind, for
that ‘fear’ thought… Thank you, Mind, for
that ‘I’m bad’ thought… Thank you, Mind,
for that ‘judgment’ thought,” and so on.

NEGATIVE LABEL REPETITION


Negative label repetition is also called
Titchener’s repetition (Titchener, 1916),
based on Edward Titchener’s discovery that
repeating any word fifty or more times be-
gins to rob it of all meaning. Even highly dis-
turbing words or phrases spawned from
schema-driven thoughts lose most of their
punch with repetition. When clients present
a self-judging thought that they find
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disturbing, encourage them to use negative


label repetition. Before starting, try to reduce
the thought to something pithy, like “bad
husband,” “selfish,” or “hurtful and mean.”
Have clients repeat the word or phrase out
loud quickly, while still pronouncing it
clearly, for at least one minute.
Then help them explore what happened
to the meaning of the word or phrase. In
most cases, clients report that the word or
phrase began to feel odd or empty—more a
sound than a word. If this technique works
for clients, encourage them to use it at home
when they notice schema-driven self-
judgments.

OBJECTIFYING THOUGHTS
One way to shrink the power of painful
thoughts is by objectifying them, imagining
them as physical objects (Hayes et al., 1999).
To use this technique, ask clients to imagine
the thought as an object, then tell you its
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color, size, shape, texture, and so on. It’s


easier for clients to distance themselves from
thoughts that have been assigned physical
properties.

CARD CARRYING
In this defusion technique, clients carry
index cards on which they write down
schema-driven thoughts as they come up.
Then, whenever these painful cognitions re-
cur, clients can remind themselves, “It’s on
the card,” and let it go.

WEARING LABELS
Painful self-judgments that show up re-
peatedly can be defused by actually wearing
them. Do this exercise together with clients
so you can model the process and share
some of the embarrassment. Each of you
should write a recurring self-judgment on a
sticky note or name tag and wear it for the
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remainder of the session. Toward the end of


the hour, share with each other how the im-
pact of the negative label has changed. Al-
though the judgment was probably disturb-
ing at first, the words may have lost much of
their power by the time you remove the
labels.

THE FOUR KEY QUESTIONS


Once a client has gained some under-
standing of defusion and is starting to use it
with schema-driven thoughts, you’ll both be-
gin to recognize which thoughts are the most
frequent and powerful. For these recurring
cognitions, especially any that block values-
based behavior, ask the client four key
questions:

1. How old is this thought? How


long has the client been thinking
this? Five years? Ten? Since
childhood?
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2. What is the function of this


thought? What is the mind trying
to achieve? Most schema-driven
thoughts, at root, are designed to
help people avoid some kind of
pain. A slightly different way to get
at the function of a thought is to
ask the client what this thought is
trying to protect him or her from
feeling.

3. How is the thought working?


Is the thought effective at protect-
ing the client? Or does the client
still struggle with the very feelings
this thought was supposed to help
him or her avoid?

4. Would you be willing to have


this thought and still act on
your values in relationships?
Even though this difficult thought
shows up and tries to drive the
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client back to old coping behaviors,


would he or she be willing to have
the thought while taking action on
valued intentions?

These questions usually help clients gain


distance from schema-driven thoughts as
they realize that these thoughts don’t work
and haven’t worked for a long time. The
fourth question embodies one of the two key
points interwoven throughout this therapy:
that clients can choose to be the person they
want to be in relationships, understanding
that in most cases this requires a willingness
to have painful, old thoughts—to take these
thoughts with them as in the monsters on
the bus metaphor.
Here’s an example dialogue with Rachel,
a forty-six-year-old woman with defective-
ness and emotional deprivation schemas, il-
lustrating how the four key questions can fa-
cilitate the distancing process:
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Rachel: I tried not to shut down and go cold.


I really did. But every time my
brother repeats all of his horror
stories about growing up with
Mom, I… I want to appreciate his
struggle, to really listen. But I turn
to ice.
Therapist: What thoughts come up when you
try to listen to him?
Rachel: He’s an asshole. All he really cares
about is himself. I took just as much
shit from her, but he doesn’t even
know about it, much less care.
Therapist: What’s the schema?
Rachel: No one cares. (Blending defective-
ness and deprivation.)
Therapist: And you’re thinking that?
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Rachel: Yeah. I don’t matter. To him or my


mother. I’m a nothing—just
someone to complain to.
Therapist: That thought really gets to you.
How old is it, do you imagine?
Rachel: How long have I had it? Since I was a
kid.
Therapist: What do you imagine the purpose
of that thought might be? What’s
your mind trying to do?
Rachel: It’s trying to keep me from being
hurt, I guess—trying to stop me
from caring about them.
Therapist: Is that working? Do you feel less
hurt and vulnerable?
Rachel: No. I get hurt all the time.
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Therapist: So what’s the outcome of those


“nobody cares” thoughts? What
happens after you buy into them?
Rachel: I’m angry and hurt. I’m tremend-
ously upset that they don’t give a
shit. It kills me that nobody cares
what I go through.
Therapist: Does anything else come out of
those “nobody cares” thoughts?
Rachel: Like I said, I get cold. I withdraw.
And then my brother complains
about that! He gets upset and says
I’m not listening.
Therapist: So, if anything, those thoughts
make you feel more hurt, rather
than less hurt. And they also pull
you away from your value of listen-
ing and understanding. Are they
working at all? Are they doing any-
thing positive for you?
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Rachel: (Shakes head.) No.


Therapist: Those thought monsters are likely
to show up any time you’re intend-
ing to really listen to and connect
with your brother. The schema gets
activated, and then the thoughts
come up, right? I’d like to ask you
something: Would you be willing to
have those thoughts and still listen
to your brother? Would you be will-
ing to stay focused so you can really
understand him?
Rachel: (After a silence.) Just assume I’m
going to have the thoughts because
I always do? And then keep listen-
ing, regardless? (Sighs.)
Therapist: It’s a hard thing, isn’t it?
Rachel: It is, but I can work on that.
Notice how the distancing questions
about the age, function, and workability of
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thoughts prepare clients to experience


schema-driven cognitions as less useful and
believable. They also make it possible to ask
for a key commitment: being willing to ex-
perience painful thoughts while choosing to
act in alignment with interpersonal values.
In this example, Rachel won’t be able to hear
and understand her brother until she accepts
and gains some distance from those “nobody
cares” thoughts.
Practicing Defusion Skills
As you can see, there are many techniques
for helping clients defuse from thoughts. All
can be effective. Sometimes the challenge is
simply remembering the techniques and de-
ciding which will be effective in different cir-
cumstances. To help with this, give clients
the Defusion Skills handout, which lists all of
the skills covered in this chapter. (Appendix
C includes an alternative handout, which
lists fewer skills and provides brief descrip-
tions of the skills listed. You can use
whichever version you prefer.)
Once you’ve taught clients all of the tech-
niques and have given them the handout, use
the following exercise to give them some
practice in choosing and using defusion
skills. Start by having clients identify four to
six schema-driven thoughts that have cre-
ated barriers to values-based interpersonal
behavior. Then briefly review the defusion
skills they’ve been learning, using the
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Defusion Skills handout to provide a


reminder.
Next, start giving voice to clients’
schema-driven thoughts, throwing them at
clients randomly. Clients can then use any
defusion skill that seems appropriate in re-
sponse. Here’s an example of this exercise
with a client named Bill, who has a subjuga-
tion schema.
Therapist: You’re being so cruel and selfish
to tell your girlfriend about things
that bother you in the relationship.
Bill: Thank you, Mind, for that thought.
Therapist: You’re being very inconsiderate of
others’ feelings.
Bill: My mind is having a “judgment”
thought.
Therapist: She’s going to get sick of you.
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Bill: I’m having the thought that she’s going


to get sick of me. It’s just a thought.
Therapist: You have to realize how selfish
you’re being. If you don’t think
about this, nobody will want to be
around you.
Bill: I hear that thought, and now I’m going
to let it go. (Spreads his fingers as
if dropping something.)
Therapist: She’s probably already mad at
you.
Bill: I’ll let that one go, too. It’s drifting away,
a silly red balloon.
Therapist: You’re too demanding.
Bill: That’s a very old thought—my mother
used to say it. All it’s doing is trying
to shut me up.
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Therapist: You’re just going around hurting


people, and then you’ll be alone.
Bill: Thanks, Mind, for the “judgment” and
“fear” thoughts.
We suggest that you do this exercise with
clients several times as they’re learning defu-
sion skills. Continue to practice defusion in
session through the rest of treatment
whenever clients experience schema-driven
thoughts in session. Carefully listen for fused
thoughts. Ignoring and failing to defuse
these thoughts in session is perilous because
clients will go home and do the same. You’ll
also lose opportunities for clients to practice
key defusion skills under your supervision.
In addition, you’ll be modeling inattention to
cognitive processes.
If clients report fusion with schema-driv-
en thoughts between sessions, ask which de-
fusion strategy they might have used with
this thought, then practice it in session.
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Encourage them to consider other defusion


techniques as well, and rehearse those in ses-
sion too.
Changing Perspective
When clients are fused with thoughts or
emotions, their identity is merged with those
private experiences. If they think, “I’m
afraid” (versus “I’m having the thought that
I’m afraid,” the self and the fear are essen-
tially indistinguishable. One goal of ACT is to
help clients detach the self from emotions
and cognitions. This is a shift from self-as-
content to self-as-context, or the observer
self. Once clients have made significant pro-
gress with defusion, self-as-context work can
be introduced over a session or two.
Explain the observer self to clients using
the concepts outlined in the handout The
Observer Self. Because this concept can be a
little challenging, you can also give clients
the handout to review later.
As is often the case in ACT, metaphors
can help clients grasp the concept of self-as-
context—and may even help them directly
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experience this perspective. Two metaphors


that we find helpful here are the movie
screen metaphor and the chessboard meta-
phor. You can also use a brief experiential
exercise to help develop the observer per-
spective. All three approaches are outlined
below.

Movie Screen Metaphor


Suggest to clients that the observer self is
a movie screen. Every day a new movie plays
on the screen—tragedies, comedies, adven-
tures, love stories. All of them are full of
emotions, like loss, hope, joy, and fear. And
all have an unending stream of ever-chan-
ging dialogue, analogous to the thoughts the
mind constantly churns out. Though the
movies, the emotions, and the dialogue con-
stantly change, the screen is always there
and remains the same.
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Encourage clients to detach from current


emotions and thoughts and simply notice all
of the experiences that have shown up on the
movie screen today and in the moment.
Suggest to clients that they can be the screen,
allowing experiences to come and go and al-
lowing thoughts to come and go.

The Chessboard Metaphor


With the chessboard metaphor, clients
come to see themselves as the chessboard it-
self, rather than any of the pieces or the out-
come of the game (Hayes et al., 1999). We re-
commend keeping a chessboard in your of-
fice to fully utilize this excellent metaphor.

The Observer Self


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Sometimes your self—the essential


you—gets merged with thoughts and feel-
ings. For example, you might have the
judgment “I’m bad” as if that were you,
as if your essential self were bad. That’s
fused thinking—the thought and the self
seem like the same thing. This contrasts
with defusion, where you say, “My mind
is having the thought that I’m bad.” You
and the thought are not the same.

You can also get merged with feelings.


Saying or thinking, “I’m afraid,” makes it
seem like you are the fear, as if your core
self is characterized by fear. That’s differ-
ent from noticing in a given moment that
you feel afraid—which is a passing emo-
tion and doesn’t define you. When you
have a feeling of fear, you’re observing
something that will change and
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pass—something that isn’t you. When you


are afraid, you are the fear.

Thoughts and feelings constantly change.


They come and go, and throughout all of
these changes you are the one who is
watching. This perspective is sometimes
called the observer self. See if you can be
aware of this observer self, this self be-
hind your eyes who watches what you
think, what you feel, and what you do
and is separate from all of that. As you
observe your self-judgments, you see
that you aren’t the same as those judg-
ments. You aren’t your thoughts, feelings,
or sensations. You are the one who ob-
serves, notices, and holds all of these
experiences.

Many parts of you have changed over the


years: you’ve gotten older, you’ve
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learned things, and you see some things


differently than you used to. Throughout
all of this, you’ve experienced a continu-
ous stream of ever-changing thoughts
and feelings. And throughout all of this,
your observer self has always been there,
never changing. See if you can sense this
deeper you.

Start by having the client list at least ten


positive and ten negative labels about him-
self or herself. Then sit across the chessboard
from the client and initiate a dialogue using
the labels. Begin by putting down a chess
piece and stating one of the negative labels
out loud, then have the client put down a
chess piece and state one of the positive la-
bels out loud. Continue until all of the labels
have been stated.
This sets the context for exploring the
metaphor as follows:
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Therapist: Some of these pieces are good,


and some are very painful. We hu-
mans struggle to get rid of all these
painful thoughts and feelings that
show up when our schemas are ac-
tivated. There are moments when
you feel insecure, and moments
when you feel very confident; mo-
ments when you feel competent,
and moments when you feel like a
failure. There are moments when
you feel awkward, and moments
when you feel real and genuine. But
what if you weren’t these chess
pieces? What if you weren’t either
the good pieces or the bad pieces?
Is there anything you could be be-
sides these chess pieces? (This isn’t
a rhetorical question; elicit a re-
sponse from the client.)
If you were a player, you could try to move
these pieces around in an effort to
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win, but that doesn’t change any-


thing; the player is still caught in
the game and invested in whether
the good or bad thoughts and feel-
ings win. The games just go on and
on. Sometimes the good pieces win,
sometimes the bad. Can you think
of anything else you might be other
than the pieces or the player?
(Again, elicit a response.)
Here’s an idea: What if you were the board?
That way you could have the pieces
but not be the pieces. The board is
in contact with the pieces. It’s aware
of the pieces and experiences the
pieces. But the board itself never
changes, whether there are more
black or white pieces and no matter
where they move. The board stays
the same. It doesn’t care about the
game or who wins or loses. So from
this space, the space of being the
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board, can you see how you can


hold all of your experiences, ob-
serving them and yet not being
them?

An Experiential Exercise in Being the


Observer Self
One effective way to help clients take the
perspective of the observer self is to guide
them in watching and describing their exper-
ience. Simply have them identify and label
thoughts, emotions, and physical sensations
out loud; for example, “I’m having the
thought that ___________… I’m having a
___________ feeling… I’m having a
___________ sensation in my
___________ ,” and so forth.
As with defusion, it’s important to contin-
ue to encourage clients to develop the
observer-self perspective throughout the re-
mainder of treatment. You can use this
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exercise to do so, or simply ask, “Can you


just watch that thought or feeling—just ob-
serve your experience as it comes and
goes—without being the experience? Can you
be the observer and not the thought or
feeling?”
Summary
The focus of this phase of treatment is on
cognitive defusion and developing the self-
as-context perspective. Defusion has four
components that are best developed sequen-
tially: watching thoughts, labeling, letting go,
and distancing. It’s important to devote suf-
ficient time and practice to this important
work, and it’s essential to note all fused
thoughts that occur in session and help cli-
ents defuse from them.
Learning to watch experience as the ob-
server self is made easier by all of your work
with defusion. And, in fact, it is closely re-
lated to defusion skills. Being the observer
self is a stance you encourage throughout
treatment, one you can facilitate with simple
questions such as “If you were the sky, what
would your weather be right now?” or
“What’s playing on your movie screen right
now?”
Chapter 7
Conducting Exposure with Defusion

As mentioned in chapter 6, ACT therapists


frequently work on affect and cognitions at
the same time, merging defusion with emo-
tion exposure. Although we’re presenting
emotion exposure separately, we encourage
you to integrate work on schema-driven af-
fect with work on schema-driven thoughts.
As with defusing from schema-driven
cognitions, clients need to learn to face
schema affect so emotional barriers won’t
block them from acting on values in their re-
lationships. This requires developing accept-
ance and willingness. Emotion exposure, in
which clients learn to observe and describe
schema affect, is the path to acceptance of
difficult emotions. It promotes willingness to
experience whatever emotional pain is ne-
cessary as clients act on their interpersonal
values.
Emotion Exposure
When clients experience schema affect in
session, fully bring the emotion into the
room. This is done by exploring, in sequence,
physical sensations, the emotion itself, re-
lated thoughts, urges to avoid the experi-
ence, and urges to react with typical coping
behaviors. This sets the stage for asking cli-
ents whether they’d be willing to have their
difficult emotions in the service of acting on
their values-based intentions.
We recommend starting with physical
sensations because it’s often easier for clients
to describe a feeling in the body than to ex-
plore emotions. You can conduct in-session
exposure either via dialogue with clients or
through guided visualization.

Exposure via Dialogue


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To conduct exposure via dialogue, follow


the sequence of steps outlined below:

1. Start with physical sensa-


tions. Ask clients what they are
feeling physically. You might use
the objectifying approach from
chapter 6 here, asking them to
imagine what physical attributes
the sensation would have if it were
a physical object; for example, “If
the sensation had a color, what col-
or would it be? What shape or size
would it be?”

2. Focus on the actual emotion.


Ask clients what emotion goes with
the physical sensations they’ve just
described. Then ask them to de-
scribe the emotion. Again, it may
be helpful to use the objectifying
approach, asking them to assign
physical characteristics, such as
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size, shape, color, and texture, to


the emotion. Encourage them to
keep finding new ways to describe
the emotion.

3. Ask clients to notice and label


thoughts. After exploring the
emotion, ask clients to notice and
label any related thoughts. Guide
them in defusing from these
thoughts using the techniques in
chapter 6. For example, encourage
them to use such phrases as “I’m
having the thought that ” or “Now
my mind is having a thought,” or to
simply say, “There’s a thought.”
(Letting-go imagery typically isn’t
used during exposure because it
distracts from the main task: ex-
periencing the emotion. Deal with
thoughts quickly—just briefly la-
beling them—then get back to the
emotion.)
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4. Ask clients to notice any im-


pulse to suppress the emo-
tion. If they observe any avoid-
ance, encourage them to resist it
and instead focus on the emotion,
trying to be as open to the feeling
as possible.

5. Help clients notice any action


urges. Ask clients whether they
notice any urges to engage in old
coping behaviors, such as with-
drawing, getting aggressive, or say-
ing something dismissive. If this is
happening, suggest that they can
simply have those urges while still
focusing on their feelings.

6. Keep circling back to emo-


tions and sensations. Here are
some questions you might ask:
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▪ “What are you


feeling right now?
Try to describe
everything you
notice.”

▪ “Has anything
about the emotion
changed? Does it
feel more or less
intense? Has it
transformed into a
different
emotion?”

▪ “What are you no-


ticing physically?”

▪ “Have your phys-


ical sensations
changed in any
way? Describe
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how they’re
different.”

7. Ask about willingness. After


clients have observed and explored
the feeling in detail, ask this key
question: “Would you be willing to
have this feeling and still follow
through on your commitment to
your values-based intention?”
(Ideally, you’d state a specific in-
tention here.) If the answer is no or
the client isn’t sure, you probably
need to do additional emotion
exposure.

The following dialogue illustrates this


emotion exposure process. In this example,
the client is a twenty-one-year-old man
struggling with subjugation and mistrust
schemas. Upon noticing the client’s schema-
driven emotional pain, the therapist brings
the client’s attention to the emotion:
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Therapist: When you had lunch with your


father this week, you knew the topic
would come up about your drop-
ping out of the engineering pro-
gram. Your intention was…
Client: I know… I meant to tell him in a
gentle way what I really want. It
didn’t happen.
Therapist: What got in the way?
Client: The fear that he’d tell me I screwed
up—that he’d be angry and maybe
walk out. So I was curt and refused
to talk about it.
Therapist: What are you noticing right now
as you remember that?
Client: The fear that he would be disgusted
with me.
Once the emotion is acknowledged, you
can move through the process outlined
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above. Here’s an example, continuing the


previous dialogue, to illustrate how this
might play out:
Therapist: What are you noticing right now
in your body? Are you experiencing
any physical sensations?
Client: I feel hot in my chest. I have a tight
feeling there.
Therapist: Does that sensation feel big or
small?
Client: Pretty big. It fills my chest.
Therapist: If it had a color, what would it be?
Client: Black—ugly black.
Therapist: Can you identify the emotion con-
nected to that feeling?
Client: I’m afraid.
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Therapist: How could you describe the fear


right now?
Client: It’s like he’s going to kill me emotion-
ally—just kick me and kick me until
I’m broken.
Therapist: How big is the feeling?
Client: Huge! The size of a truck… It doesn’t
fit inside of me. It’s too big.
Therapist: And the color?
Client: The same—black.
Therapist: If thoughts come up, just label
them, saying to yourself, “There’s a
thought.” Then get back to the feel-
ing. What are you noticing now
about the emotion?
Client: I’m just scared that he’s going to re-
ject me. I feel alone, like there’s no
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one. He’s going to crush me if I


don’t do what he wants.
Therapist: Okay, just thank your mind for
that thought. What do you observe
about the feeling now?
Client: I’m still scared, but I’m noticing that
there’s also a little anger.
Therapist: See if there’s a part of you trying
to get away from the feeling—trying
to distract or distance yourself from
it.
Client: Yeah, I’m thinking about applying to
school next fall.
Therapist: Just notice that and then see if
you can really open yourself to the
fear that your dad is going to reject
you. Stay with that. Do you still
have the heat and tightness in your
chest?
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Client: The tightness is there, but the heat


not so much.
Therapist: What do you notice now?
Client: It’s just there. I’m afraid of him. I re-
member him hitting me when I was
a kid, his big hands.
Therapist: Just notice that thought and let it
go. Does the fear make you want to
do something?
Client: It makes me want to be very cold,
very walled off.
Therapist: What’s happening with the fear?
Client: It’s kind of sitting there, in my chest.
And I’m looking at it, like it’s some
wild animal in the zoo.
Therapist: I want to ask you something that
might be important. Would you be
willing to have this fear and still
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gently and directly tell your dad


what you want?
Client: You mean be honest, not cold?
Therapist: Yes.
Client: (Long pause.) Okay. I’m seeing him
Thursday. I’ll talk to him then.
Notice that in this example the fear
doesn’t go away or change much. What’s im-
portant is that the client stays with it, that he
observes and learns about the experience.
This is a way of practicing willingness: the
willingness to feel pain in the service of his
values. Following the in-session exposure,
he’s able to make a commitment that wasn’t
possible before: to take the fear with him and
assert his needs with his father. Also notice
that the emotion is the center of the work.
The therapist acknowledges thoughts and
avoidance impulses but keeps returning to
the affect and sensations. This is how you
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keep the exposure going: by repeatedly ask-


ing, “What are you noticing about the emo-
tion now?”

The Special Case of Anger


Anger is a tricky emotion to do exposure
with because it can show up both as schema
affect and as a schema coping behavior.
Anger is often a component of schema affect,
particularly with emotional deprivation and
entitlement schemas. Exposure work is ne-
cessary for clients to develop willingness to
carry the anger while acting on their values-
based intentions in relationships.
On the other hand, with defectiveness,
failure, abandonment, and unrelenting
standards schemas, angry feelings and ag-
gressive behavior tend to fall into the cat-
egory of schema coping behaviors, covering
other, more painful emotions. In the case of
defectiveness and failure, anger often helps
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people avoid the primary pain of shame.


With abandonment and unrelenting stand-
ards, anger can form an emotional bulwark
against fear.
If anger or aggression is functioning as a
schema coping behavior, you must look be-
neath to uncover the hidden, avoided affect.
The focus of exposure should be the underly-
ing emotions.

Exposure via Guided Visualization


As mentioned, you can also conduct emo-
tion exposure via guided visualization, and
that approach is described below. As you’ll
see, the visualization uses steps similar to
those outlined previously, starting with
physical sensations before moving to emo-
tions. The client in this example is struggling
with an abandonment and instability schema
that was triggered when her boyfriend had a
busy period at work and wasn’t available for
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several days. When they finally spoke, in-


stead of following her intention of exploring
his feelings about the relationship, she ex-
ploded. The anger was functioning as a
schema coping behavior, to help her avoid
the fear of abandonment, so exposure to the
fear was the ultimate goal:
Therapist: Close your eyes and visualize your
boyfriend. Look back for a moment
at that argument… Let yourself be
aware of your anger and what
you’re saying… Notice your physical
reactions, paying close attention to
your body’s sensations. Notice any
difficult, uncomfortable sensations,
perhaps in your stomach, chest,
head, or shoulders. If you note an
uncomfortable sensation, just stay
with it. See if you can stop wrestling
with that sensation and just observe
it. The point isn’t to like the feeling,
but to experience it as what it is: a
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sensation in part of your body. Keep


observing it and see if you can feel
exactly where that sensation is loc-
ated, where it begins and ends…
You might even imagine that it has
a shape or color. See if you can let
go of any struggle or sense of de-
fense against this sensation.
As you observe physical sensations, notice
whether any thoughts, judgments,
or evaluations come up… If they do,
just notice them and label them,
then let them go. Say to yourself,
“There’s a judgment” or “Thank
you, Mind, for that thought.” Then
let it go without getting involved
with it. Just keep noticing your
thoughts and letting go of each as it
arises.
Now notice any impulses. How do you feel
pulled to react as you visualize the
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argument? Are you feeling pulled to


escape? Do you want to attack?
Notice the urges to engage in old
schema coping behaviors.
As you’re observing all of the sensations,
thoughts, and impulses that your
anger brings up, notice how the
pain is connected to your schema
and see if you notice any other emo-
tion underneath the anger. Perhaps
you were feeling afraid when you
became angry. See if there is fear
there now… Are there any other
emotions, such as shame or
sadness?
Just observe any feeling that is below your
anger. Stay with the feeling and
watch it. See how big it is. See its
shape. Notice if it might have a
color.
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If you find yourself wanting to escape these


feelings, gently bring your attention
back to them. These are the feelings
that your anger was covering.
Continue in this way for another few
minutes, having clients watch and explore
the feelings beneath their anger. Then, be-
fore asking clients whether they would be
willing to feel the underlying emotions while
acting on their values-based intentions, have
them visualize doing so:
Therapist: Now bring back the image of your
boyfriend and see him clearly. Ima-
gine that this is the moment when
you intend to gently ask him about
his feelings about the relationship.
Let yourself be aware of your feel-
ings: the anger, if it’s there, along
with the feelings beneath your an-
ger, the emotions that are so painful
to experience. Now imagine gently
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asking your boyfriend about his


feelings. Notice your schema emo-
tions as you ask, and simply let
them be whatever they are. Are you
willing to have them while you ex-
plore his feelings?
Encourage clients to continue with this
aspect of the visualization for a few mo-
ments, simultaneously holding the schema-
related affect and an image of their new, in-
tended behavior.
Exposure and Defusion Combined
Several techniques and exercises merge ex-
posure and defusion into a single process. At
root, these exercises are all aimed at accept-
ance of schema-driven thoughts and feelings,
which leads to greater willingness to act on
interpersonal values.

Exploring the Flip Side


In the exercise Exploring the Flip Side,
exposure consists of listing and considering
schema-driven thoughts and feelings and the
costs of old schema coping behaviors. The
physical properties of the written list are
used to help facilitate defusion. Then related
values are written on the opposite side of the
paper, creating the context for an experien-
tial exercise revealing that values-based be-
havior and schema-related pain are insepar-
able. This sets the stage for exploring willing-
ness. Here are the specific steps:
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1. On a large index card or sheet of


paper, list clients’ frequently
triggered schema-driven thoughts
and feelings.

2. Label all of these thoughts and


feelings “Schema-Related Pain,”
then encourage clients to observe
the thoughts and feelings.

3. Help clients defuse from the


thoughts by having them count the
number of words in each thought,
then the number of letters. Have
clients notice the color of the ink
and ask them to read the thoughts
backward.

4. Ask clients, “What have these


thoughts and feelings cost you?
What specific things do they keep
you from doing?”
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5. Explore how these thoughts and


feelings have acted as barriers to
values-based behavior and write
the underlying value(s) on the flip
side.

6. While clients are in contact with


their schema-related pain, ask
them what they want to do with the
list of thoughts and feelings. Do
they want to push it further away,
tear it up, or throw it away?

7. Have clients notice that pushing


the list of thoughts and feelings
away or throwing it away also
moves away the value(s) written on
the flip side.

Here’s a sample dialogue illustrating this


process. In this example, the client is a fifty-
two-year-old woman struggling with an un-
relenting standards schema:
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Therapist: That sadness keeps showing up,


doesn’t it? Those high, high stand-
ards keep getting triggered. And
when you don’t live up to them…
Client: I start feeling down and get angry at
myself.
Therapist: (Folds a sheet of paper.) Let’s
write that schema-related pain
down. There’s the sadness. And
there’s anger at yourself. Can you
get in touch with your anger? It
happened just a few days ago with
your business partner.
Client: Yeah, I can feel it.
Therapist: And how about thoughts—what
thoughts go with the anger?
Client: Thoughts like “I’m doing it wrong”
and “This isn’t good enough.”
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Therapist: (Writes everything down.) What


are you noticing in your body?
Client: I feel heavy.
Therapist: Still sad?
Client: Yeah.
Therapist: Okay, just be with that. Let’s look
at the two thoughts you mentioned.
(Shows the list to the client.) How
many words in each of them?
Client: Um…four…and four.
Therapist: Okay, let’s count the letters in that
first thought.
Client: Are you kidding? Okay…fourteen.
Therapist: And how many letters in the
second one?
Client: Eighteen.
Therapist: What color is the ink?
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Client: Green.
Therapist: Can you read the first thought
backward?
Client: Wrong it doing I’m.
Therapist: Okay, can you have these fourteen
green letters and observe them?
Can you have them just as they are,
just letters and lines on the paper?
What’s that like after a while?
Client: They kind of lose their meaning.
Therapist: What’s happening with your sad-
ness and anger?
Client: They are still there.
Therapist: That’s fine. This schema-related
pain—the sadness and anger, and
the thoughts (tapping the pa-
per)—what has this pain kept you
from doing in your relationships?
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Client: It’s kept me from keeping my


word—from doing what I said I was
going to do even if it isn’t perfect.
Therapist: Right. Let’s write that down on
the other side. (Turns the paper
over and writes the value on the
opposite side, then turns the paper
back to the side with the schema-
related emotions and thoughts.)
What could you do with this paper,
with these feelings and thoughts, if
you wanted to get rid of them?
Could you put it across the
room—maybe even throw it away?
(Moves the paper far from the cli-
ent.) You can put the sadness, an-
ger, and thoughts farther away from
you, but if you do, notice what else
is farther away. What else is on the
paper?
Client: My value.
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Therapist: Right. The farther away your sad-


ness, anger, and difficult thoughts
are, the farther you are from your
values. I’m wondering if you could
take this piece of paper with you
and keep it with you for the rest of
the week. Would you be willing to
have the feelings and thoughts on
this piece of paper if it means that
you’ll also be closer to your value of
keeping your word even if you have
to do things imperfectly?

Exposing the “Worst Self”


Exposing the “Worst Self” is a guided
visualization in which exposure consists of
having clients vividly recollect a time when
schema coping strategies led to regrettable
behavior. To begin, have clients think of a
time when they behaved as their “worst self”
with others. Then, to facilitate defusion, help
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them notice that they have an observer self


that watches the “worst self” and sees
everything it does. Help them take the self-
as-context perspective and observe the feel-
ings, thoughts, and behaviors of their “worst
self.” As they observe this “worst self,” help
them notice the distinction between the core,
unchanging self and the schema-driven
thoughts, feelings, and behaviors. This dis-
tinction reveals to clients that they are not
synonymous with their worst self. Rather,
they are the self that watches and has always
watched every thought and feeling, both
good and bad. Here’s an example script for
this visualization (based on Ciarrochi &
Bailey, 2008):
Therapist: You’ve told me about times when
schema thoughts and feelings were
so strong that you acted in ways you
regret. You might say you behaved
as your “worst self” with others.
Think back to a time when you were
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at your worst… Imagine, as vividly


as you can, being this “worst self”…
Notice the feelings that push and
pull at you. Notice how your “worst
self” thinks. Let yourself be aware of
specific thoughts… See how your
“worst self” behaves with others
and how far this is from your
values.
Now notice that, within you, there’s some-
body looking at this “worst self.”
This is a self that watches your
“worst self” and witnesses
everything it experiences. This part
of you is the observer self.
Even though your thoughts, feelings, urges,
and sensations are continuously
changing, there is still a consistent
you throughout. There is a you that
can watch all of your experiences
without being those experiences or
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struggling with them. Just become


aware of this person behind your
eyes that watches your “worst self.”
Can you experience what it feels
like to be the observer?
Now consider this: If you can observe your
“worst self,” then you are not the
same as that “worst self.” If you can
observe the thoughts and feelings
connected to your worst self, then
you aren’t equivalent to those
thoughts and feelings. You are the
observer. Remember the chess-
board? You aren’t the pieces on
either side, fighting all those
battles. You aren’t your thoughts,
feelings, and sensations. You are
the one who observes, notices, and
holds all of these pieces.
Can you imagine that you are not your
breathing and your body and its
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sensations, that you are not your


emotions or your thoughts? Many
parts of you have changed over the
years. Your age has changed. Your
appearance has changed. Your
thoughts and feelings are constantly
changing. But the observer self has
always been there, never changing.
See if you can sense this deeper
“you.” Think of yourself as being
like the sky, being an unchanging
perspective from which you notice
and hold the ever-changing weather
of your awareness. See if you can let
go of your attachment to and
struggle with difficult emotions,
thoughts, sensations, and impulses.
Now notice all of the experiences that have
shown up today—particularly the
difficult thoughts and feelings of
your “worst self.” And as you do,
notice that you’re here now,
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watching all of it. See if you can


make space to be the observer right
now. You are exactly who you
should be. Nothing needs to be
changed. Nothing needs to be fixed.
This visualization goes to the heart of
ACT: developing a new relationship with
private events. It helps clients learn to ob-
serve thoughts and feelings, rather than be-
ing drawn into maladaptive interpersonal
behavior. While clients can’t stop the
thoughts and feelings that arise as manifest-
ations of childhood trauma and condition-
ing, they can learn to watch these private ex-
periences with detached nonjudgment while
choosing to act on valued intentions, rather
than reacting with old coping behaviors.

Dropping the Rope


Dropping the Rope is an experiential ex-
ercise that combines exposure with lessons
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about behavioral flexibility. You’ll need a


somewhat short piece of rope—about six feet
long—for this exercise. Here are the specific
steps:

1. Ask about a recent schema-trigger-


ing situation and have the client
describe the associated feelings
and thoughts, then objectify this
schema-related pain by asking
questions about its shape, size, col-
or, weight, texture, and so on. You
can also ask whether any of these
physical qualities are changing or
whether the pain is moving in any
way.

2. When the client has clearly de-


scribed the schema-related pain as
an object, explain that you’re tak-
ing the object out of him or her and
putting it in you. Act out this pro-
cess of transferring the pain.
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3. Hold one end of a rope and ask the


client to hold the other end. Then
inquire about how the client has
been relating to this pain when it
shows up.

4. Pull on the rope and let the client


struggle with you as the schema-
related pain. Remind the client of
the feelings and thoughts. Pull the
client around or let the client try to
get away by pulling you for a
minute or two.

5. Encourage the client to explore al-


ternative solutions. If necessary,
suggest dropping the rope.

6. After the client drops the rope,


continue to represent the pain and
follow the client around wherever
he or she goes.
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7. Help the client notice that even


after he or she drops the rope, the
schema-related pain is still there.
However, the client is now free to
move around, including toward
important values. Even though the
pain is still there, the client is set-
ting the direction rather than being
constrained and locked in a
struggle.

Clients may not arrive at the idea of drop-


ping the rope on their own. You may need to
guide them to this solution, as in the follow-
ing dialogue. The client in this exchange has
a subjugation schema that’s been activated
by her relationship with her roommates. She
has trouble with their low standards of
cleanliness in the kitchen and bathroom but
hasn’t mentioned this because she believes
that the feelings of others always come first.
Recently she got up the nerve to schedule a
meeting to discuss the problem. However,
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doing so set off fear that she’ll be asked to


move out, along with schema-driven
thoughts, such as “After this they won’t even
talk to me,” “I’ll have to find another place to
live,” and “I can’t stand the mess, but I’d bet-
ter not rock the boat.” As the dialogue be-
gins, client and therapist are holding either
end of the rope:
Therapist: (Pulls.) Okay, I’m the fear. I’m the
thought that they won’t even talk to
you and that you’ll have to find a
new place to live. (Pulls the rope
harder.) What are you going to do?
This is a big worry, a big struggle.
Client: (Pulls on her end.) I don’t know. I
hate this. I’m always so
afraid—afraid to say what bothers
me.
Therapist: (Starts to pull the client out of her
chair.) I’m pulling you. You have to
come with me wherever I pull you.
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You can’t do what you want to do.


They’re going to kick you out… They
won’t even talk to you…
Client: What am I supposed to do?
Therapist: I don’t know. What are your
choices? (Pulls hard.) You can go
where I take you. Just be quiet and
don’t rock the boat.
Client: I don’t want to do that.
Therapist: Okay. But I’m going to keep
pulling you around anyway. I’m
your fear and your thought that
they’ll reject you. (Pulls the client in
one direction after another.)
Client: Hey, I could drop the rope. (Lets go
of the rope.)
Therapist: How does that feel? Go ahead;
move around.
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Client: I feel freer.


Therapist: (Following the client closely.)
Look at what’s happening. Even
though you dropped the rope, the
schema-related pain is still there.
It’s close by. But notice what it feels
like to have it there without the
struggle to get away or to fix it,
without wondering whether to
speak up or be quiet. Notice how,
when you aren’t struggling with the
rope, you have more freedom to
choose where you want to go.
Client: Yeah, now I can move anywhere.
Therapist: Notice how your hands and feet
are no longer occupied and you can
choose your path. The pain is still
there, but it isn’t controlling your
destination anymore.
Summary
In essence, this book’s approach to
recurring, schema-driven interpersonal
problems revolves around two key processes:
clarifying values and then committing to
specific values-based intentions. As long as
clients are able to move in the direction of
their values, the work remains action ori-
ented. But when cognitive and emotional
barriers show up, the focus must shift to ex-
posure and defusion. At the end of every ex-
posure or defusion exercise, it’s important to
bring the focus back to willingness. Would
clients be willing to carry difficult feelings or
thoughts with them as they act on particular
intentions? Would they be willing to have all
of the experiences that come up as they
choose to relate to others based on their val-
ues? If the answer to these questions is yes,
the focus can shift back to planning and act-
ing on valued intentions. If the answer is no,
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you’ll need to continue to work on barriers


using exposure and defusion techniques.
In the end, what matters is that clients be
free to choose how they relate to others,
rather than letting schema-driven affect,
thoughts, and behaviors choose for them.
The goal is to help them learn to watch the
pain—waves of fear or shame, seemingly
endless streams of frightening or judgmental
thoughts—and still act in ways that support
the relationships they care about.
Chapter 8
Working with Six Key Processes

This chapter covers common treatment is-


sues that come up in both individual and
group therapy for interpersonal problems
and gives some suggestions on how to ad-
dress them. There are six processes integral
to this treatment, and all will arise
throughout the treatment process, regardless
of the order presented in the protocol:

▪ Creative hopelessness and


workability

▪ In-session activation of schemas

▪ Activation of schemas in day-to-


day life

▪ Values-based planning

▪ Defusion
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▪ Exposure

All of these processes are recurring fea-


tures of treatment, and the therapy will con-
tinue to cycle through them. Learning how to
navigate these processes and when to imple-
ment them is critical to good outcomes. In
this chapter, we’ll focus on five aspects of
each key process:

1. How to recognize when to use the


process—the distinguishing cues or
signals that indicate that a particu-
lar process is appropriate

2. How to discuss the process with


clients—how to label and introduce
the process in therapy

3. Criteria to help guide treatment


choices
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4. Key techniques for implementing


the process in therapy

5. Common problematic client reac-


tions and how to respond

Note that the criteria section (item 3) will


help you determine whether you need to
work on other processes before continuing
with the key techniques outlined in the next
section. If the issues mentioned in the criter-
ia section don’t apply to a given client, you
can proceed to implement the techniques
and strategies discussed in the next section
(item 4, on key techniques for implementing
the process in therapy).
Creative Hopelessness and Workability
Creative hopelessness is a critical process in
therapy, and one that reemerges quite often.
This process is especially crucial for getting a
“buy in” for treatment. If clients don’t accept
that avoidance and control are the problem
and the target of treatment, you can’t pro-
ceed with the approach in this book. These
clients won’t have the willingness and motiv-
ation to experience the difficult schema-re-
lated pain that comes up during exposure
and values work, yet this pain must be accep-
ted if clients are to take steps in valued direc-
tions. Therefore, throughout therapy it is
critical to remind clients of the long-term
costs of old coping behaviors and help them
recognize that schema-related pain is
unavoidable.

1. Recognizing When to Use Creative


Hopelessness and Workability
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Several key signals can alert you that


working with creative hopelessness and
workability would be timely and appropriate:

▪ When clients are attempting


to avoid or change a difficult
private experience. Clients may
say things like “I just want to feel
like I belong; I don’t want to feel so
lonely and different” or “I want to
feel less depressed.”

▪ When clients are using


schema coping behaviors. Cli-
ents may use schema coping beha-
viors in session with the therapist,
or they may describe situations
when they have recently used a
schema coping behavior in a rela-
tionship outside of session. If a cli-
ent pushes you away, creates dis-
tance, minimizes the importance of
the relationship, or gets angry with
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you in session, this may be a


schema coping behavior. Also be
alert to instances when clients de-
scribe these kinds of behaviors out-
side of therapy, saying things like
“I yelled at her,” “I didn’t go to the
job interview,” or “I kept calling
her over and over again and she
wouldn’t pick up.”

▪ When avoidance was a barrier


to following through on
values-based intentions. Cli-
ents may reveal this by saying
things like “I didn’t tell her how I
felt because I felt too guilty” or “I
didn’t do the homework you as-
signed because it made me too
anxious.”

2. Discussing Creative Hopelessness


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First, work with clients to identify all of


the different ways in which they have at-
tempted to avoid or get rid of particular feel-
ings, thoughts, or experiences connected to
their schemas. Help them assess the costs of
avoidance, including both short-term and
long-term outcomes. Creative hopelessness
hinges on recognizing that schema-related
pain is unavoidable and that attempting to
avoid it only leads to more pain and suffering
in the long run.

3. Criteria to Guide Treatment Choices


Regarding Creative Hopelessness
If clients don’t accept that their schema-
related pain is unavoidable, use the
strategies in the next section, on key tech-
niques, to help develop willingness to experi-
ence primary pain. Likewise, if clients don’t
recognize that schema coping behaviors only
work temporarily and then make things
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worse in the long run, again use the


strategies in the next section to help en-
gender creative hopelessness. Once clients
accept these two key points, proceed to as-
sessing barriers to alternative behaviors and
working on exposure, defusion, and values
clarification to help them face their barriers.

4. Key Techniques for Cultivating


Creative Hopelessness
There are several effective techniques for
helping clients arrive at the difficult but
pivotal place where they experience creative
hopelessness. Start by identifying their mal-
adaptive coping behaviors and avoidance
strategies. For example, you might ask about
a specific incident, saying something like
“What did you do when you felt this mistrust
or fear that this person will leave you?” Or
you might ask a more general question, like
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“How do you usually behave when you feel


this fear?”
Next, explore the outcome of old coping
behaviors. For example, you might ask,
“What happened after you called her again
and again? What was the outcome? How did
she respond? Did you feel better or worse?”
Once you’ve established that schema coping
behaviors haven’t managed to permanently
remove this pain and have actually led to
more pain, help clients realize that the
primary pain is unavoidable and is in them.
Suggest that they don’t have to remove this
pain in order to behave differently and that
perhaps the answer lies in relating to this
pain differently: getting closer to it and more
curious about it rather than running away
from it.
Finally, connect all of these schema-re-
lated experiences, and especially the costs of
old coping behaviors, to various relational
domains and a variety of past experiences.
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Here are some examples of questions you


might ask: “How many times did this feeling
of deprivation come up for you with your
partner yesterday?” “How many times did
this come up with your friends over the past
week?” “How many times did this come up at
work over the past month?” Help clients no-
tice that this feeling has been with them for a
long time and may be unavoidable. You
might ask something like “Could it be that
every time you take a step toward being
more intimate with someone, this fear that
the person will leave you will come up, along
with the urge to create distance and
disconnect?”

5. Responding to Problematic Client


Reactions to Creative Hopelessness
When trying to arrive at creative hope-
lessness, the most typical problematic reac-
tion is when clients can’t accept that their
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primary pain is unavoidable and therefore


continue to try to eliminate and decrease this
pain. In this case, you can have a discussion
about avoidable versus unavoidable pain, in-
cluding the things we can and cannot con-
trol. You can also describe the relationship
between primary and secondary pain. To this
end, help clients notice the specific ways that
avoidance makes their pain worse in the long
run.
You can use specific creative hopeless-
ness metaphors, such as the quicksand meta-
phor or the metaphor of digging a hole (de-
scribed in chapter 4), or you can simply ask
clients about it directly, saying something
like “Check in with your own experience.
Have you ever managed to permanently get
rid of this feeling? Have you ever been able
to permanently eliminate or control the
thoughts and feelings connected to your
schema?”
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You can also bring up commitment, say-


ing something like “Would you be willing to
have this feeling of shame if it brings you
closer to being the honest and genuine per-
son that you want to be? Would you be will-
ing to bring this feeling of shame with you
and still express your needs in the
relationship?”
Activation of Schemas in Session
Schemas are frequently triggered in session
in both individual and group therapy. For ex-
ample, clients who have a defectiveness
schema will feel criticized by the therapist. In
group therapy, they will also sometimes feel
criticized by other group members or by the
group in general. These incidents provide an
excellent opportunity to respond to schema
activation.
Help clients notice when their schemas
are triggered in session and how they react.
Work with them to identify the schema and
the trigger and to label various aspects of
their experience, including thoughts, emo-
tions, sensations, urges, and behaviors con-
nected to the schema, with a particular focus
on schema coping behaviors. The objective is
to help clients become increasingly mindful
of schema-related experiences, especially the
costs of their typical coping behaviors, to
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help build motivation to choose to respond


differently in their relationships.
It’s worthwhile to take every opportunity
to connect clients’ in-session coping behavi-
ors to outcomes of these coping behaviors in
other relationships. This is a powerful move
because it provides an opportunity for clients
to practice acceptance of schema-related
pain in the service of values-based behavior.

1. Recognizing In-Session Activation of


Schemas
There are a couple of key signals that in-
dicate a schema has been triggered in
session:

▪ When clients show strong af-


fect. If clients seem to be feeling
angry, ashamed, embarrassed,
guilty, disappointed, or afraid, this
may indicate schema activation.
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▪ When clients use a schema


coping behavior with you.
Watch for times when clients cre-
ate distance, seek reassurance, get
clingy, withdraw, become sub-
missive, or blame, attack, or avoid
you. Schema coping behaviors may
also show up in the form of ex-
plaining or justifying their behavi-
or or getting defensive.

2. Discussing In-Session Activation of


Schemas
When introducing schemas and identify-
ing which schemas are relevant to clients, ex-
plain that everyone has schemas, including
you, the therapist. Also explain that it’s inev-
itable that schemas will sometimes be
triggered in the course of therapy. As you
work with clients to identify the thoughts,
feelings, sensations, and urges that come up
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when the schema is triggered, don’t be at-


tached to labels and descriptions from this
book (or elsewhere). It’s often a good idea to
use clients’ language to describe and label
their schema experience.
Also, seek permission from clients to
point out moments when their schemas have
been activated in session, and ask them to
try to notice and point out those moments as
well. Ask for permission to stop them in mo-
ments when identified schema coping beha-
viors occur in the room. Predict that, al-
though this will be an uncomfortable experi-
ence, this exposure to schema affect will be
an important part of treatment. Point out
that there’s something positive about these
situations, in that they provide opportunities
to learn about their schemas and coping be-
haviors and to try out new behaviors.
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3. Criteria to Guide Treatment Choices


Regarding In-Session Activation of
Schemas
If clients can’t recognize when their
schemas have been triggered, use the
strategies in the next section, on key tech-
niques, to help them notice that this is hap-
pening. If they do generally notice when this
is occurring, proceed to assessing barriers to
alternative behaviors and working on expos-
ure, defusion, and values clarification to help
them face their barriers.
If clients aren’t aware of potential trig-
gers that may activate their schemas, use the
Interpersonal Triggers Worksheet from
chapter 4 to help them identify people and
events that commonly trigger their schemas.
If clients haven’t accepted that schema-
related pain is unavoidable, shift the focus
back to creative hopelessness.
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If clients can’t identify and bring mindful


awareness to their schema-related experi-
ences (the thoughts, feelings, urges, sensa-
tions, and memories that come up when
schemas are triggered), shift the focus to de-
veloping mindfulness.
If clients are highly fused with their
schema content, it’s probably a good idea to
work on defusion techniques.
If clients haven’t recognized that avoid-
ance is creating distance from their values,
shift the focus to values clarification and
committing to values-based action to help
them differentiate how they have been inter-
acting with how they would like to be in
relationships.
If clients don’t have much willingness to
experience their schema-related pain, work
on creative hopelessness and values
clarification.
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4. Key Techniques for Working with


In-Session Activation of Schemas
Mainly at the beginning of treatment, but
sometimes later, you’ll need to help clients
recognize moments when their schemas have
been triggered. Ask them about it directly.
Here are some examples: “I’m wondering if
you’re feeling controlled right now, like you
have no choice.” “Are you feeling like I’ve
shamed you somehow?” “It seems like you’re
feeling as though I don’t get you—maybe
even deprived, like I won’t meet your needs.
Does it seem that way to you?” Then explore
which schema was activated, the thoughts
and emotions that came up for clients in the
moment, and any coping behaviors they are
using.
Next, link clients’ in-session activation of
schemas to similar situations in various in-
terpersonal domains; for example, “Do you
notice how the same feeling that comes up
between you and your girlfriend—where you
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feel like you’re the bad guy and will be


blamed and punished—is coming up for you
right now with me?”
Also identify the coping behaviors clients
are using with you and then connect those to
coping behaviors they use in other relation-
ships; for example, “It seems like you’re try-
ing to explain or justify yourself right now, as
if you feel you’ve done something wrong.
Does it feel that way to you?” or “I wonder if
your pattern of being late to therapy is simil-
ar to the coping behavior we identified that
you use with your boyfriend, where you cre-
ate distance and withdraw in order to protect
yourself from feeling abandoned. Do you
think that may be coming up in here?”
In a group setting, you can ask either the
person whose schema has been triggered or
other group members which schema they
think has been activated and then explore
what the trigger might have been. However,
when inviting other group members to
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comment on one person’s schemas or


schema coping behaviors, be sure to encour-
age the group to relate to the experience,
normalize it, and explore it compassionately.

5. Responding to Problematic Client


Reactions to In-Session Activation of
Schemas
After clients become more aware of their
schemas and the costs of old coping behavi-
ors, they may still have difficulty behaving
differently. One possible reason for this is
that they don’t notice the opportunity to be-
have differently. Another probable factor is
that they habitually attempt to avoid their
schema-related pain, whereas staying in con-
tact with this pain is necessary for behavioral
change. Here are a few strategies that may
help:

▪ Increase clients’ exposure to


schema affect and have them
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notice the moment when urges to


engage in old coping behaviors
come up for them. You can do this
via visualizations of recent
schema-triggering events and
keeping clients immersed in the
schema experience. Methods for
keeping them in contact with
schema experience include mindful
breathing, identifying sensory ex-
periences in the moment, and re-
cognizing the current behavior as
an avoidance strategy. For ex-
ample, you could say, “What would
it be like to stay with this feeling
that you’ll never feel that your
partner understands you or will
meet your needs? What is that ex-
perience like? Where do you feel
that in your body?”

▪ Help clients recognize the moment


of choice by pointing out that a
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schema coping behavior just oc-


curred in the room, identifying
what happened to trigger the
schema, and exploring the
thoughts, feelings, and urges that
led to the schema coping behavior.

▪ When clients use old coping beha-


viors in session, identify the coping
behavior and help them come up
with alternative responses. For ex-
ample, if a client says that feeling
deprived or misunderstood creates
an urge to demand or explain, ex-
plore alternative behaviors they
can engage in when they have that
urge, such as express a feeling,
state some sort of appreciation, or
write about their experience in a
journal.

▪ Provide positive reinforcement


when clients display new behaviors
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in session. Either directly or indir-


ectly, acknowledge that they used a
different behavior.
Working with Activation of Schemas in
Day-to-Day Life
When clients describe problematic interper-
sonal interactions in day-to-day life, help
them figure out whether schema activation
played a role in the difficulty. Explore which
schema may have been activated and what
the trigger was. Then have them label vari-
ous aspects of the experience, including
thoughts, emotions, sensations, urges, and
behaviors connected to the schema, with a
particular focus on schema coping behaviors.
As with in-session activation of schemas, the
objective is to help clients become increas-
ingly mindful of schema-related experiences,
especially the costs of their typical coping be-
haviors, to help build motivation to choose to
respond differently in their relationships.

1. Recognizing When Schemas Have


Been Activated out of Session
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There are a couple of key signals that in-


dicate clients’ schemas were triggered in day-
to-day interactions:

▪ When clients describe a situ-


ation where they used schema
coping behavior. Watch for stor-
ies about interpersonal interac-
tions that include clients’ schema
coping behaviors, such as giving in,
demanding, distancing, attacking,
or withdrawing.

▪ When clients have strong af-


fect while telling a story.
Watch for times when clients dis-
play strong anger, sadness, shame,
guilt, or embarrassment while de-
scribing interpersonal interactions.

2. Discussing Schema Activation in


Day-to-Day Life
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When clients report day-to-day interac-


tions that seem schema related, ask directly
whether they think a schema was triggered.
If they aren’t sure, suggest some possible
schemas; for example, “As I listen to you de-
scribe this situation with your wife, I’m won-
dering if that ‘bad guy’ feeling was triggered
for you at that time.”
Also help clients identify the problematic
coping behavior. For example, you might
ask, “What did you do in that moment when
you felt deprived? How did you behave?” In
situations where clients didn’t actually fall
back on old coping behaviors, ask about any
urges; these can provide insight into clients’
typical maladaptive behavior patterns.
Finally, and crucially, identify the impact
and cost of the coping behavior in clients’ re-
lationships; for example, “What happened
after you withdrew? Did the relationship feel
better or worse? What did the other person
do?”
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3. Criteria to Guide Treatment Choices


Regarding Schema Activation in Day-
to-Day Life
If clients haven’t accepted that schema-
related pain is unavoidable, shift the focus
back to creative hopelessness.
If clients understand and accept that the
pain is unavoidable but still continue to em-
ploy old coping behaviors in day-to-day in-
teractions, shift the focus to values clarifica-
tion and committing to values-based action
to help them differentiate how they have
been interacting with how they would like to
be in relationships. Also help them notice the
various moments of choice to behave differ-
ently by slowing down the story and identify-
ing the specific thoughts, feelings, or urges
that were driving their behavior. Assist them
in identifying alternative behaviors to engage
in at those times.
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4. Key Techniques for Responding to


Schema Activation in Day-to-Day Life
If clients are to choose to behave differ-
ently when their schemas are activated, they
must be able to notice triggering situations
as they occur or, better yet, be able to foresee
that certain situations may activate their
schemas. The Schema Events Log and
Schema Triggers Worksheet, both in chapter
2, began to build these skills, and the
Schema Coping Behaviors Worksheet, in
chapter 3, helped them identify the coping
behaviors they tend to use in specific situ-
ations. The Interpersonal Experiences Diary,
from chapter 4, brings all of these skills to-
gether and allows clients to identify signals
that can serve as indicators that a schema
has been activated.
In session, use entries from the Interper-
sonal Experiences Diary to conduct in-ses-
sion visualizations bringing clients back into
salient situations. Have them observe all
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aspects of the interaction or situation, in-


cluding emotions, thoughts, physical sensa-
tions, and schema-driven urges. Then ask
what they actually did and whether they re-
sorted to problematic coping behaviors.
Focus on the moment of choice—that key
point when a schema has been activated but
clients haven’t yet responded. This is the
time when they can choose to engage in
values-based behavior rather than old coping
strategies. Help them identify and list signals
that will allow them to mindfully recognize
that they’ve reached this critical point. These
signals include both triggering situations and
the resulting emotions, thoughts, sensations,
and urges. These can serve as red flags that a
schema has been activated, providing an op-
portunity to take advantage of the moment
of choice.
You can help clients notice the moment
of choice by slowing down the story and
identifying moments when they could have
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chosen a different behavior. For example you


can point out that any time they have an urge
to criticize their partner, they can choose to
appreciate their partner instead, or that any
time they have the thought that they want to
end their relationship, they can hug their
partner instead. Help clients identify specific
thoughts, urges, or feelings that drive them
to use a particular schema coping behavior
and then explore alternative, values-based
behaviors they can engage in instead.

5. Responding to Problematic Client


Reactions to Schema Activation in
Day-to-Day Life
As mentioned in regard to in-session
schema activation, even after clients become
more aware of their schemas and the costs of
old coping behaviors, they may still have dif-
ficulty behaving differently. The approach
outlined above will help them identify the
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moment of choice, but even then they may


struggle to engage in new behaviors. In this
case, work with clients to identify specific
new responses to replace old coping
behaviors.
You can use role-playing exercises based
on recent triggering situations to help clients
practice these new behaviors. For example,
you might play the role of the client’s critical
mother and have the client notice his or her
experience and urges and practice respond-
ing differently.
Values-Based Planning
Values-based planning is an integral com-
ponent of treatment and will reemerge fre-
quently throughout therapy. Clients who are
struggling with recurring interpersonal prob-
lems are often unclear about their values in
relationships or how they’d rather be inter-
acting. Their behaviors in relationships have
mainly been driven by the desire to avoid
schema-related pain and feared outcomes.
Once clients understand the costs of mal-
adaptive coping behaviors, values-based
planning can begin. Help clients identify key
interpersonal values in all relevant interper-
sonal domains, then use these as the basis
for developing specific intentions. Work with
clients to review past triggers and predict fu-
ture situations where they can engage in
their new, values-based behaviors.
As therapy proceeds, frequently check in
about whether clients’ behaviors are
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consistent with their values. When they re-


sort to old, maladaptive coping behaviors,
help them notice and label what’s going on
and assess the costs while also reminding
them of their commitment to new ways of re-
sponding. From time to time, review the ef-
fectiveness of current intentions based on
previous outcomes and new or evolving is-
sues in relationships and help clients plan
new values-based actions as appropriate. Be-
cause a crucial aspect of values is that they
are personal and freely chosen, it’s essential
that you keep clients’ stated values in mind
and effectively discriminate between avoid-
ant and values-based behavior.

1. Recognizing When to Use Values-


Based Planning
Several key signals can alert you that val-
ues work would be timely and appropriate:
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▪ When clients use maladaptive


coping behaviors in session.
This can show up in several forms.
Clients may make demands of you,
minimize the importance of the re-
lationship, attempt to quit therapy,
seek reassurance, worry about you,
comply with all of your interven-
tions and statements, or blame or
attack you.

▪ When clients tell you a story


about using maladaptive cop-
ing behaviors in day-to-day
life. Clients may say things like “I
yelled at my husband,” “I ignored
her,” “I kept trying to explain,” “I
told him he’s a jerk,” or “I kept in-
sisting that she listen to me.”

▪ When clients are about to


enter a previously identified
triggering situation. An
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example is a holiday dinner with a


critical mother, an interaction with
a demanding boss, or needing to
set limits and boundaries with a
child who’s acting out.

2. Discussing Values-Based Planning


Explore the costs of old coping behaviors.
Directly ask whether specific behaviors
moved clients closer to or farther away from
their values and whether the behavior made
the relationship feel better or worse. You can
also explore the costs of problematic coping
behaviors in the therapeutic relationship and
whether something similar is occurring in
other relationships. For example, you might
say, “When I notice you withdrawing and
disconnecting in session with me, it feels like
it creates distance between us and I feel con-
fused about what’s going on for you. Do you
think that withdrawing creates distance in
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your relationship with your boyfriend as


well?”
Help clients explore how they can behave
differently both in session and in day-to-day
life. Continuing with the previous example,
in session you might say, “So, in those mo-
ments when you’re triggered and get the urge
to withdraw and disconnect from me, how
can you let me know what’s going on for
you? What could you do differently to bring
yourself closer to your value of being intim-
ate and expressive in relationships?” Then
you can extend this to clients’ key relation-
ships; for example, saying “In those mo-
ments when you feel rejected by your boy-
friend and you get the urge to run away and
disconnect from him, what can you do to let
him know what’s going on for you? What can
you do or say that will bring you closer to be-
ing the expressive and open person you want
to be in your relationship?”
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Remind clients of the barriers to valued


action that you’ve previously identified and
ask them whether they’d be willing to have
those difficult thoughts and feelings while
taking action on their new, values-based
intentions.

3. Criteria to Guide Treatment Choices


Regarding Values-Based Planning
If clients aren’t clear on their interper-
sonal values, use the Valued Intentions
Worksheet in chapter 5 to help them clarify
their values. If they aren’t clear on the
thoughts and feelings that act as barriers to
their values, use the Assessing Barriers
Worksheet in chapter 5 to explore and
identify barriers. If clients aren’t willing to
feel the emotional pain that comes up as they
act on valued intentions, focus on creative
hopelessness to build willingness or use ex-
posure and defusion techniques to help
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clients accept and tolerate their primary


pain.

4. Key Techniques for Implementing


Values-Based Planning
After helping clients identify key values in
relevant interpersonal domains, to work col-
laboratively to identify values-based inten-
tions: specific behaviors that would reflect
those values in current relationships. One
way to identify specific values-based inten-
tions is by exploring clients’ schema-related
pain, thoughts, and coping behaviors. These
often reveal a lot about clients’ values. For
example, someone with an abandonment
and instability schema who copes by discon-
necting, withholding, and distancing from
others may describe not wanting to be vul-
nerable and intimate with people for fear of
being abandoned. This may reveal a desire
for connection and intimacy. This
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information can be used to explore specific


intentions related to being vulnerable and
expressing feelings in relationships. Another
example would be a client with a defective-
ness schema who fears disappointing others
and who copes through compliance and sur-
render. This may reveal a value of being
more authentic, genuine, and assertive in re-
lationships. In this example, you could even
ask something like “What if you could be 100
percent certain that your husband would
never abandon you—how would you behave
differently? Would you be more honest or
ask for what you want more often?”
Another way to use clients’ schema-re-
lated pain to identify potential values-based
intentions is similar to the exercise Explor-
ing the Flip Side, from chapter 7. Write
clients’ schema-related thoughts and feelings
on one side of a piece of paper and then, on
the other side, list what these thoughts and
feelings have stopped them from doing. This
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helps clients identify specific values-based


intentions while also clearly illustrating the
costs of avoidance.
Once values-based planning commences,
help clients come up with specific intentions
for the week and also underscore that these
new behaviors are alternatives to their old
schema coping behaviors—that these are be-
haviors to be used when they experience that
moment of choice, when they have the op-
portunity to respond by moving in valued
directions rather than reacting in habitual
ways.

5. Responding to Problematic Client


Reactions to Values-Based Planning
A common problem when doing values
work is clients being overly invested in the
outcome of a particular intention (something
they cannot control), rather than being in-
vested in taking the steps toward being the
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kind of person they want to be (something


they do have control over). In this case, a
hoped-for outcome is driving clients’ behavi-
or more than values are. For example, a cli-
ent with a subjugation schema may have an
intention to express particular needs to his
or her partner but not follow through be-
cause of fear that the other person will get
mad or feel hurt. Here are some strategies to
use in such situations:

▪ Help clients defuse from stories


about ideal and feared outcomes.

▪ Help clients recognize that ideal or


feared outcomes are connected to
their schemas—that they exist in
the mind and not in the world.

▪ Assess the function of the stories


and whether the desire for a partic-
ular outcome is moving clients
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closer to or farther away from their


values.

▪ Return the focus to the value and


reassess its importance, as well as
the costs of not acting on this value
in relationships.

▪ Revisit the topic of what we can


and cannot control. Help clients
notice that, no matter what the
outcome, by acting on their inten-
tions they are getting closer to
their values and how they want to
relate to others. Remind them that
we can’t control how others will re-
spond; we can only control how we
conduct ourselves.

▪ Explore creative hopelessness in


regard to the pain that clients are
trying to avoid.
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▪ Do exposure work with any schema


affect that clients are trying to
avoid.
Defusion
Defusion techniques create distance from
cognitive barriers and promote willingness
to have schema-driven thoughts in the ser-
vice of acting on values-based intentions. To
begin this work, help clients recognize that
painful thoughts have been barriers to acting
on their values and suggest that in order to
relate to others differently they must learn
how to relate to their thoughts differently.
A wide variety of exercises, metaphors,
and other strategies can be employed to help
clients with defusion, and chapter 6 provides
a great deal of guidance on these approaches.
However, defusion is also a stance that you
should model in how you relate to clients
and their thoughts. Take every opportunity
to notice clients’ schema-related verbal beha-
vior, including thoughts, memories, stories,
explanations, justifications, reasons, inter-
pretations, and assumptions, then model a
defused stance by bringing awareness to the
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process of thinking by labeling these behavi-


ors as thoughts, memories, stories, explana-
tions, and so on, and by holding them lightly.
Holding clients’ verbal behavior lightly in-
volves labeling it for what it is and suggest-
ing alternative thoughts, explanations, and
reasons. You might also connect particular
thoughts and explanations to specific schem-
as and past experiences or identify the func-
tion of the verbal behavior in the moment.
For example, you might say, “That’s an inter-
esting explanation. What schema is that
reason connected to?” or “How is having this
rule working for you? To me, it seems like
one of those deprivation thoughts that pulls
you toward making demands.”
Note that although defusion and expos-
ure are discussed separately in this section,
in practice they often go hand in hand and
are conducted simultaneously. As soon as
clients begin to defuse from schema-related
thoughts, schema affect typically shows up.
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And as soon as schema affect shows up, it


triggers schema-related thoughts. Therefore,
it’s often necessary to alternate between de-
fusion and exposure techniques or to work
on defusion and exposure simultaneously.

1. Recognizing When to Use Defusion


There are a couple of key signals that can
alert you that defusion work would be timely
and appropriate:

▪ When clients bring up


thoughts connected to their
schemas. This includes stories,
explanations, predictions, worries,
reasons, and judgments. Here are
some examples: “I’m just going to
fail at whatever I try.” “She always
makes me feel bad.” “I don’t trust
him.” “I’m ugly.” “I disappoint
people.” “I never get it right.” “It’s
because he’s too selfish.” “She
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broke up with me because I’m


boring.”

▪ When clients bring up


schema-related stories about
other people’s behaviors. This
includes assigning motives or in-
tentions to others and predictions
about how others will respond:
Here are some examples: “She’ll
just end up hating me and leaving
me.” “He’s going to cheat on me.”
“She’ll get angry if I express how I
feel.”

2. Discussing Defusion
As mentioned, chapter 6 provides a wide
variety of techniques for cognitive defusion,
and working with these will go a long way to-
ward helping clients understand and cultiv-
ate this skill. In addition, call attention to
mental activity, thoughts, and stories
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connected to clients’ schemas using such


phrases as “You’re having a prediction
that…” or “Your mind is telling you a story
that…” Look for opportunities to externalize
clients’ mind, saying something like “What’s
your mind saying to you about that situ-
ation?” You might even give the client’s mind
a name, choosing a name other than the cli-
ent’s. For example, with a client named Re-
becca, you might establish the name Suzie
for her mind and then sometimes say “What
is Suzie telling you to do?” or “That sounds
like something Suzie would say.”
Also try to connect particular verbal be-
haviors associated with clients’ schemas to
all the different domains in which they show
up. This helps clients see that schema
thoughts show up across different relation-
ship domains—an indication that they exist
inside the client, rather than being specific to
particular relationships or interactions. For
example, if clients have a frequent thought
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related to their partner not meeting their


needs or not understanding them, you can
help them notice the many different relation-
ships where that thought comes up—with
their boss, with their mother, and so on. Al-
ternatively, ask them to them recall the first
time this thought came up for them in a rela-
tionship or point out times when that
thought has come up in regard to you, the
therapist.

3. Criteria to Guide Treatment Choices


Regarding Defusion
Defusion strategies can be used with
most of the cognitive content that clients
bring up. The only case in which you might
delay defusion is with thoughts that describe
an outcome of a particular schema coping
behavior. For example, consider a client who
brings up a thought that she believes her
husband is thinking about divorcing her.
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Before jumping in with defusion, you want to


assess the workability of her schema coping
behaviors and help her understand how this
thought drives her to behaviors that may ac-
tually lead to being abandoned. If she copes
with her abandonment and instability
schema through constantly accusing, cling-
ing, and seeking reassurance from her hus-
band, then it’s likely he may indeed be feel-
ing frustrated with her. In this situation, it
would be better to use strategies that focus
on creative hopelessness or values. You could
also work on creative hopelessness, values,
and defusion simultaneously by helping the
client recognize that the thought “He’s going
to divorce me” pulls her toward using coping
behaviors (such as accusing or blaming) that
maintain her abandonment schema and pull
her farther away from her values. It’s critical
to distinguish between thoughts that predict
actual likely outcomes of the client’s coping
strategies versus fusion with thoughts that
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block values-based behavior. For the former,


start with assessing the workability of beha-
viors and values clarification before moving
into defusion; for the latter, defusion would
be appropriate.

4. Key Techniques for Implementing


Defusion
When you notice clients buying into a
particular explanation or interpretation,
work with them to develop several alternat-
ive explanations or interpretations for the
same event, then help them notice that they
can arbitrarily choose which explanation or
interpretation they decide to buy into. In a
group setting, you could also ask other group
members for alternatives and use this to lead
into a discussion of how different people are
more likely to buy into certain thoughts de-
pending on their schemas.
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Discuss the function of schema-driven


thoughts with clients. To this end, you might
say something like “Once a schema gets
triggered, many thoughts will serve the pur-
pose of avoiding schema-related pain. These
thoughts will try to pull you toward using old
coping behaviors and running away from the
difficulty.” Explain that schema-related
thoughts are often strongest when people
start taking steps toward their values. En-
courage clients to notice the function of their
thoughts whenever they take steps in valued
directions. You might ask something like
“When you started acting on your intentions
this past week, what did you notice your
thoughts trying to do? How were they pulling
you to behave? What was their goal or
purpose?”
Ask clients whether they are willing to
have difficult or painful thoughts in the ser-
vice of acting on their values. Here are a
couple of examples: “Would you be willing to
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have the thought that your girlfriend will get


angry if you express yourself and still let her
know that your feelings were hurt?” “Would
you be willing to have the thought that your
husband is selfish and unable to meet your
needs and still ask him to give you a ride to
work on Tuesday?”
In a group setting, you can ask group
members to label schema-driven thoughts
that come up for individuals during the ses-
sion; for example, “What kind of thought is
that—a predicting thought, a judgment, an
explanation?” or “What schema might that
thought be connected to?” Encourage the
group to notice which thoughts and stories
are connected to which schemas. Also en-
courage group members to notice judgments
and label them as such.
In a group setting, you might also ask
group members how they think a particular
thought is working for one group mem-
ber—whether that thought moves the person
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toward or away from his or her interpersonal


values. You could even ask other group
members how strongly they believe or buy
into a particular thought, story, or explana-
tion that one group member has expressed.

5. Responding to Problematic Client


Reactions to Defusion
A common problematic issue that arises
with clients regarding defusion is that they
are so fused with the content of their
thoughts that they view these thoughts as
reality, which leads them to want to under-
stand their thoughts rather than create dis-
tance from them. Clients believe that these
thoughts represent a truth about themselves
or their problems and that analyzing and as-
sessing these thoughts will help them change
their behavior, understand who they are,
solve problems, or predict and prevent
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certain outcomes and patterns. Here are


some strategies to use in such situations:

▪ Help clients notice how particular


thoughts act as barriers to values.

▪ Discuss the difference between


problem solving and ruminating,
worrying, and fusion. Explore
which thoughts are productive,
bring clients closer to their values,
and help them solve problems, and
which thoughts are repetitive,
damaging schema-driven thoughts.

▪ Explore whether these thoughts


have brought clients closer to solv-
ing a particular problem or have
helped change their behavior, and
whether realizations necessarily
lead to behavioral change.
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▪ Assess the workability of holding


thoughts too tightly and whether
particular thoughts make clients
feel better or worse.

▪ Explain that we don’t have to de-


fuse from all of our thoughts, that
defusion is just a choice we have in
the moment. We can let our minds
control us, or we can choose to cre-
ate distance from mental content
and hold it lightly. It’s an option,
not a strategy to use with every
negative thought.
Exposure
Emotion exposure techniques promote will-
ingness to face schema-driven affect. The
goal of exposure is to help clients build ac-
ceptance of unavoidable schema-related pain
and willingness to have that pain in the ser-
vice of acting on values-based intentions. To
begin this work, help clients recognize that
painful emotions have been barriers to act-
ing on their values and suggest that in order
to relate to others differently they must learn
how to relate to their emotions differently.
Exposure is difficult work, so it’s essential to
focus on clients’ key values, which will
provide motivation for them to experience
schema-related pain. Be careful to use expos-
ure only with clients’ primary pain, not the
secondary pain due to maladaptive coping
behaviors, which is both avoidable and
unnecessary.
As mentioned in the section on defusion,
exposure to schema affect will bring up
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thoughts connected to the schema. There-


fore, when schema-related thoughts show up
during exposure, help clients defuse from
those thoughts, then get back to the emotion.
Thoughts that come up during exposure are
attempts to avoid painful schema affect.
Much of this aspect of the work involves
carefully balancing defusion and exposure or
working with these two processes
simultaneously.

1. Recognizing When to Use Exposure


Several key signals can alert you that ex-
posure to emotions would be timely and
appropriate:

▪ When clients’ schemas are


triggered in session. Watch for
times when clients are angry,
ashamed, or defensive or express
any strong schema affect.
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▪ When clients engage in mal-


adaptive coping behaviors in
session or recount an event
where they engaged in those
behaviors. Watch for times when
clients seek reassurance, offer jus-
tifications, or are demanding, dis-
tancing, compliant, belittling, min-
imizing, and so on. Also be alert for
stories of behaving in these ways in
day-to-day life.

▪ When clients identify an emo-


tion as a barrier to a values-
based intention. Examples are
such statements as “I didn’t ex-
press my feelings because I felt
ashamed,” “I didn’t ask for help be-
cause I felt guilty,” and “I didn’t
take time for myself because I
didn’t want to be alone.”
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▪ When clients display emotion-


ally avoidant behaviors.
Examples of this are ruminating,
intellectualizing, and incongruent
affect, such as laughing when talk-
ing about a shameful experience.

2. Discussing Exposure
When clients accept that the problem
isn’t schema-related pain, but rather at-
tempts to eliminate or avoid that pain, they
are in a position to experience and explore
creative hopelessness. That sets the stage for
discussing exposure. Explain that part of the
solution is to get closer to the pain and relate
to it differently, rather than running away
from it. As ever, highlight the many costs of
emotional avoidance and suggest acceptance
and willingness as an alternative.
You can use various techniques from
chapter 7, such as the exercise Exploring the
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Flip Side, to help clients see that the farther


away their schema-related pain is, the
farther away their values are. Explain that
schema-related pain will often be part and
parcel of acting on their values, and also ac-
knowledge that exposure is difficult and
painful, but also a necessary step if they are
to engage in new behaviors. For example,
you might say something like “It seems like
every time this deprivation schema shows
up, it feels so painful and unbearable that
you run away from it by getting angry and
making demands. We’ve been discussing
that you want to be able to express your
needs nonjudgmentally and calmly with your
partner. It seems that this painful sense of
being deprived has stood in the way of ex-
pressing your needs differently. To help you
express your requests calmly and nonjudg-
mentally, maybe we need to bring up that
deprivation feeling right here, in this room,
and really look at it, sit with it, and learn how
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to relate to it differently. Maybe that would


help you behave differently when it shows
up. Would you be willing to give that a try?”

3. Criteria to Guide Treatment Choices


Regarding Exposure
Before conducting exposure, obtain cli-
ents’ permission and provide a rationale for
doing so. Always conduct exposure fairly
early in the session so that time remains to
process and discuss the experience; other-
wise, clients may leave the session feeling
unsettled.

4. Key Techniques for Implementing


Exposure
An effective way to conduct exposure is to
use imagery with a recent schema-triggering
event. Have clients visualize the situation
and events leading up to the moment when
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they engaged in old coping behaviors. As


they approach that moment, have them label
all of the emotions, sensations, and urges
coming up just before they engaged in the
problematic behavior. Help them identify
this as the moment of choice, when they can
differentiate between urges and actions and
choose to respond in alignment with their
values. This can provide a visceral experi-
ence that they can have a very strong urge to
engage in one behavior and still choose to do
something else.
During emotion exposure, help clients
observe and describe their emotional experi-
ence. You might objectify a specific emotion
by asking clients to describe its shape, size,
color, texture, and weight, along with where
it is located in the body and any movement
of the emotion. You can also make comments
about clients’ nonverbal behavior, such as
“Your shoulders look heavy,” “It seems like
you’re holding your breath right now,” or
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“Your hands are tightened into fists.” Help


them notice all of the physiological sensa-
tions that accompany the emotion.
You can also connect a recent schema-
triggering event and the associated emotions
to other situations in the client’s life, includ-
ing early childhood memories, and to other
interpersonal domains. You can ask ques-
tions like “How many times has this feeling
come up for you this week? How many times
this month?” “With whom has this feeling
come up? Can you think of anyone close to
you that this feeling hasn’t come up with?”
“Can you remember a time during your
childhood when this feeling came up?” The
goal of these questions is to help clients re-
cognize that this feeling is unavoidable and
exists within them, not in external circum-
stances. For example, if a client believes that
his failure schema gets triggered only in his
current romantic relationship, you can ask
him whether it has ever shown up in other
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romantic relationships, in relationships with


siblings or parents, or at work.
During any exposure, encourage clients
to make space for their experience and to be
compassionate and gentle with it. Here are
some examples of how you might help them
create a little more space for painful feelings:
“How much of this emotion are you experi-
encing right now—40 percent, 70 percent?
Would you be willing to have 5 percent or 7
percent more of this experience if that would
bring you closer to acting on your values?”
“See if you can be willing to breathe in just a
little bit more of this pain.” “Can you make
the space in your body to have all of your
experience?”
You can also ask clients to put a hand on
the part of their body where they feel their
emotional pain and then send warmth and
compassion to that area. Alternatively, have
them imagine that their schema-related pain
is a crying baby who needs to be nurtured
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with soothing kindness. Another approach is


to help clients notice how harsh they’ve been
with their own pain. Than ask them to think
about how they would relate to a friend who
was experiencing this pain. Yet another op-
tion is to have clients welcome their schemas
out loud; for example, “Welcome depriva-
tion. Welcome defectiveness.”

5. Responding to Common Problemat-


ic Client Reactions to Exposure
A common problem that arises around
exposure is that clients have difficulty re-
maining in contact with schema affect and
the discomfort that arises for both client and
therapist. Clients struggle with staying with
the schema experience, and therapists may
have difficulty bringing clients back to the
exposure. The following strategies can be
used to help clients build willingness to stay
in contact with schema-related pain:
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▪ Explain the rationale for exposure.


You can do this using the exercise
Exploring the Flip Side or by work-
ing with the monsters on the bus
metaphor. Make sure clients agree
that being farther away from
schema pain creates further dis-
tance from their values. Also re-
mind them that schema-related
pain is unavoidable.

▪ Clarify clients’ values and reassess


the level of importance of values
related to the exposure.

▪ Explore the workability of avoid-


ance through creative hopeless-
ness. Work with clients to get very
clear on the specific costs of their
avoidance of schema-related pain
and what impact this has on partic-
ular relationships. Connect specific
instances of avoidance or
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unwillingness to have pain to spe-


cific schema coping strategies that
have been damaging clients’
relationships.

▪ Assist clients in cultivating self-


compassion through mindfulness
exercises.

▪ Use defusion simultaneously with


exposure.
Summary
As you can see from how the six processes
discussed in this chapter are interwoven,
conducting ACT for interpersonal problems
is, by necessity, very fluid. Always be sensit-
ive and responsive to what’s occurring in the
room in any given moment and be willing to
shift focus if that’s what’s called for. Further,
because of the number of potential schemas,
the possibility of multiple schemas, and the
many forms schema coping behavior can
take, this approach must also be tailored to
the individual client. Keep clients’ personal
values in mind throughout, and be sure to
understand their particular situation, includ-
ing which emotions tend to be primary
schema affect and which show up as coping
behaviors, and in what situations.
That said, when first using this approach
in individual therapy, you may want to con-
sult the protocol outlined in appendix C for
guidance on the general sequence of events.
387/611

And even if you won’t be using this approach


in group therapy, we recommend that you
read through appendix C to get an idea of
how the processes and techniques might
evolve.
Conducting ACT for interpersonal prob-
lems can be a delicate balance. You may have
occasional missteps, especially at first. But if
you follow your own values in regard to help-
ing clients overcome schema-related pain
and interpersonal difficulties, you will chart
a course toward healing—one that helps cli-
ents enjoy a richer and more satisfying life
where their interpersonal interactions are in-
formed by their values, rather than by early
maladaptive schemas and old coping behavi-
ors that aren’t relevant to current circum-
stances. Using the approach in this book, you
can help clients be who they want to
be—with friends, family members, lovers,
and others—and this is surely one of the
388/611

most powerful transformations any of us can


hope for.
Appendix A
Schema Questionnaire

The following questionnaire, adapted from


the Young Schema Questionnaire with the
permission and assistance of Jeffrey Young,
PhD, is useful for determining which schem-
as are most relevant to clients. The version
below is just for reference. If you wish to use
a similar questionnaire in your practice,
please visit schematherapy.com, where you
can purchase the most current version of Jef-
frey Young’s questionnaire for research or
clinical use.
Rate the following statements using the scale
below:
1 = Completely untrue of me
2 = Mostly untrue of me
3 = Slightly more true than untrue of me
4 = Moderately true of me
5 = Mostly true of me
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6 = Describes me perfectly

Abandonment and Instability (ab)

1. I am fearful that people I love will


die or leave me.

___________ 2. I get clingy with


people when I feel that they are go-
ing to leave me.

___________ 3. My support system


feels unstable.

___________ 4. I find myself falling


in love with people who aren’t cap-
able of or willing to commit to me.

___________ 5. People have always


moved in and out of my life.

___________ 6. When someone I


love pulls away, I feel desperate.
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___________ 7. My obsession with


the idea that my lovers will leave me
drives them away.

___________ 8. The people I have


the closest relationships with are un-
predictable. Sometimes they are
there for me, and sometimes they
are not.

___________ 9. I feel like I need


people more than others do.

___________ 10. I feel like I will be


alone toward the end of my life.

Mistrust and Abuse (ma)

___________ 1. I have the expecta-


tion that people will hurt me or use
me.

___________ 2. People close to me


have consistently abused me.
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___________ 3. I know that it is


only a matter of time before the
people who are important in my life
will betray me.

___________ 4. I must protect my-


self and be on guard.

___________ 5. People will take ad-


vantage of me if I am not careful.

___________ 6. I regularly set up


tests for people to determine wheth-
er they are really on my side.

___________ 7. I tend to hurt oth-


ers before they can hurt me.

___________ 8. I fear that people


will hurt me if I allow them to get
close to me.

___________ 9. When I think about


what people have done to me, I get
angry.
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___________ 10. The people who I


should have been able to trust have
physically, verbally, or sexually ab-
used me.

Emotional Deprivation (ed)

___________ 1. I don’t get as much


love as I need.

___________ 2. I feel like no one


really understands me.

___________ 3. I am usually attrac-


ted to cold partners who can’t meet
my needs.

___________ 4. I don’t feel connec-


ted, even to the people who are
closest to me.

___________ 5. I have not had one


special person in my life who wants
to share himself or herself with me
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and cares about what happens to


me.

___________ 6. I don’t have anyone


in my life to give me warmth, hold-
ing, and affection.

___________ 7. I do not have a per-


son in my life who really listens and
is tuned in to my true needs and
feelings.

___________ 8. I find it difficult to


let people guide or protect me even
though it is what I want.

___________ 9. I find it difficult to


let people love me.

___________ 10. I feel lonely most


of the time.

Defectiveness and Shame (ds)


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___________ 1. If others really


knew me they couldn’t love me.

___________ 2. Because I am inher-


ently flawed and defective, I am not
worthy of love.

___________ 3. I have secrets that


I will not share even with the people
closest to me.

___________ 4. I am to blame for


my parents being unable to love me.

___________ 5. I present a false


self that hides the real me because
the real me is unacceptable.

___________ 6. I tend to be drawn


to people who are critical and reject-
ing of me.

___________ 7. I tend to be critical


and rejecting of others, especially
those who seem to love me.
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___________ 8. I tend to devalue


my positive qualities.

___________ 9. I feel a lot of shame


about myself.

___________ 10. Exposure of my


faults is one of my greatest fears.

Social Isolation and Alienation (si)

___________ 1. I feel very awkward


in social situations.

___________ 2. I don’t know what


to say at parties and other gather-
ings. I feel dull and boring.

___________ 3. I feel like the


people I want as friends are above
me in some way, such as appear-
ance, status, wealth, education, ca-
reer, or popularity.
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___________ 4. I would prefer to


avoid rather than attend most social
gatherings.

___________ 5. I feel that I am un-


attractive—too thin, fat, short, tall,
ugly, and so on.

___________ 6. I feel like I am dif-


ferent from other people.

___________ 7. I don’t feel like I


belong. I am a loner.

___________ 8. I feel like I am on


the outside of groups.

___________ 9. My family was dif-


ferent from the other families when I
was growing up.

___________ 10. I feel like I am not


part of the community at large.
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Dependence and Incompetence


(de)

___________ 1. I feel less like an


adult and more like a child when it
comes to dealing with responsibilities
of daily life.

___________ 2. I do not have the


capability to get by on my own.

___________ 3. I do not cope well


by myself.

___________ 4. Other people are


better at taking care of me than I am
at taking care of myself.

___________ 5. If I don’t have


someone to guide me, I have trouble
tackling new tasks.

___________ 6. I can’t do anything


right.
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___________ 7. I am inept.

___________ 8. I don’t have com-


mon sense.

___________ 9. I do not trust my


own judgment.

___________ 10. Everyday life is


overwhelming to me.

Failure (fa)

___________ 1. I feel that I am less


competent than other people.

___________ 2. I feel like a failure


when it comes to achievement.

___________ 3. I feel like most


people my age are more successful
in their work than I am.
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___________ 4. I was a failure as a


student.

___________ 5. I feel like I am the


least intelligent person in my group.

___________ 6. I feel humiliated by


my failures in the area of work.

___________ 7. I feel that I do not


measure up in terms of my accom-
plishments, and it makes me feel
embarrassed around other people.

___________ 8. I feel that people


believe that I am more competent
than I really am.

___________ 9. I feel that I don’t


possess any special talents that
really count in life.

___________ 10. I work at a level


that is below my potential.
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Entitlement (en)

___________ 1. “No” is an answer


that I have trouble accepting.

___________ 2. When I don’t get


what I want, I get angry.

___________ 3. I am special and


should not have to accept or be held
to normal restrictions.

___________ 4. I always put my


needs first.

___________ 5. I have a very diffi-


cult time getting myself to stop
drinking, smoking, overeating, or en-
gaging in other problematic
behaviors.

___________ 6. I lack discipline


when it comes to completing routine
or boring tasks.
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___________ 7. I act on impulses


and emotions that result in
consequences.

___________ 8. When I cannot


reach a goal, I become frustrated
and give up.

___________ 9. I insist that things


get done my way.

___________ 10. My need for imme-


diate gratification can get in the way
of my reaching a long-term goal.

Subjugation (su)

___________ 1. I let other people


control me and my life.

___________ 2. I worry that if I


don’t fulfill the wishes of others, they
will get angry, retaliate, or reject
me.
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___________ 3. The major decisions


in my life are not in my control.

___________ 4. I have difficulty de-


manding that other people respect
my rights.

___________ 5. I really worry about


pleasing people and getting their
approval.

___________ 6. I go to great
lengths to avoid conflict or confront-
ations with others.

___________ 7. I give more to oth-


ers than they give to me.

___________ 8. I experience the


pain of other people deeply, which
leads me to take care of the people
I’m close to.

___________ 9. If I put myself first,


I feel guilty.
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___________ 10. I am a good per-


son because I think of others more
than I think of myself.

Unrelenting Standards and Hyper-


criticalness (us)

___________ 1. I do not accept


second best. I must be the best at
most of what I do.

___________ 2. I feel like nothing I


do is ever quite good enough.

___________ 3. I strive to keep


everything in perfect order.

___________ 4. I need to look my


best at all times.

___________ 5. I don’t have time to


relax because I have so much to
accomplish.
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___________ 6. I push myself so


hard that my personal relationships
suffer.

___________ 7. I put myself under


so much pressure that my health
suffers.

___________ 8. When I make a


mistake, I deserve strong criticism.

___________ 9. I am very
competitive.

___________ 10. Wealth and status


are very important to me.
Interpreting Your Client’s Schemas

10–19: Very low. This schema prob-


ably does not apply to your client.

20–29: Fairly low. This schema may


apply only occasionally.

30–39: Moderate. This schema is an


issue in your client’s life.

40–49: High. This is definitely an


important schema for your client.

50–60: Very high. This is definitely


one of your client’s core schemas.
Appendix B
Research Outcomes

This appendix outlines results of a study of


the effectiveness of a ten-week group therapy
ACT protocol for interpersonal problems.
(The protocol used was the basis for the ap-
proach outlined in appendix C.) The ran-
domized, controlled study, conducted by Avi-
gail Lev at the Wright Institute, used the pro-
tocol with a group of forty-four male clients
at a community-based clinic for recovery
from substance abuse in Berkeley, California.
Participants were assigned to one of two
groups: treatment as usual (consisting of 22
participants) and the ten-week protocol plus
treatment as usual (22 participants). (Treat-
ment as usual was a day-treatment recovery
program that included 12-step study, relaxa-
tion training, anger management, relapse
prevention, and a host of other services.) The
Inventory of Interpersonal Problems
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(IIP-64; Horowitz, Alden, Wiggins, & Pincus,


2000) was used as an assessment tool before
and after the ten-week treatment program.
Researchers looked at several hypotheses,
but the main hypothesis of this study was
that ACT treatment would result in a reduc-
tion of maladaptive interpersonal function-
ing as compared to treatment as usual. This
hypothesis was tested via an examination of
participants’ pre- and post-treatment scores
on the IIP-64. The table at the end of this ap-
pendix compares pre- and post-treatment
test scores for participants in the treatment
versus control group. (As a side note, the
IIP-64 demonstrated excellent internal con-
sistency, with Cronbach’s a = 0.96 at post-
treatment, consistent with prior research.)
A mixed factorial analysis of variance
(ANOVA) was performed to examine wheth-
er participants in the treatment versus con-
trol group exhibited differential changes in
their IIP-64 scores over time. Overall, there
411/611

was a main effect of assessment time, such


that participants had lower IIP-64 scores at
the post-treatment assessment (M = 1.20, SD
= 0.63) as compared to the pre-treatment as-
sessment (M = 1.45, SD = 0.66), F(1, 42) =
13.074, p < 0.01, η2 = 0.237. The effect size
indicates that assessment time explained
23.7 percent of the variance in IIP-64 scores.
This main effect is qualified, however, by a
significant interaction between experimental
group and assessment time, F(1, 42) = 18.35,
p < 0.001, η2 = 0.304, such that participants
in the ACT condition group exhibited a signi-
ficant decrease in IIP-64 scores from pre-
treatment (M = 1.64, SD = 0.66) to post-
treatment (M = 1.09, SD = 0.62), t(21) =
5.41, p < 0.001, while control group scores
did not change significantly from pre-treat-
ment (M = 1.27, SD = 0.62) to post-treat-
ment (M = 1.31, SD = 0.64), t(21) = –0.486,
p = 0.63, ns. Participants did not differ signi-
ficantly on their IIP-64 scores by group, F(1,
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42) = 1.84, p = 0.67, ns, indicating that the


two samples were matched on their levels of
maladaptive interpersonal functioning prior
to treatment. The effect size of the interac-
tion term indicates that the interaction
between treatment group and assessment ex-
plained 30.4 percent of the variance in
IIP-64 scores. This effect size can be con-
sidered quite large (J. Cohen, 1988), imply-
ing that the ACT treatment resulted in a
large and potentially meaningful reduction
of participants’ maladaptive interpersonal
functioning, beyond the reduction in these
behaviors in the control group.
An independent samples t-test compar-
ing the pre- and post-treatment IIP-64 score
differences between the two treatment
groups supported the hypothesis that parti-
cipants in the ACT treatment group (MPost
– MPre = –0.55) would exhibit a greater re-
duction in maladaptive interpersonal func-
tioning as compared to those in the control
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group (MPost – MPre = 0.05), t(42) = –4.28,


p < 0.001, d = –1.23. The Cohen’s d repres-
ents quite a large effect size and indicates
that the difference between the mean scores
for the treatment group is 1.23 standard de-
viation units larger than the difference
between the mean scores for the control
group.
In sum, the main hypothesis was suppor-
ted by the data from the IIP-64. Participants
who completed a ten-week ACT treatment
exhibited greater improvement in their inter-
personal functioning as compared to parti-
cipants in the control group. Given prior re-
search establishing empirical support for
ACT treatment for a wide variety of psycho-
logical problems (see Ruiz, 2010), these res-
ults are quite promising for the treatment of
interpersonal problems, although caution
must be used in the interpretation of these
data, given the small sample size.
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Note: Negative difference scores indicate


a reduction in problem behaviors from pre-
treatment to post-treatment.
Appendix C
Group Protocol (Written with Koke
Saavedra)

This appendix provides a complete pro-


tocol for conducting ACT for interpersonal
problems in a group setting over the course
of ten ninety-minute sessions. The ideal
group size is eight to ten members. However,
the protocol can easily be adapted to other
group sizes and formats. In addition, you
may wish to adjust the amount of time de-
voted to different elements of each session,
depending on the needs of group members
or the focus of the group.
A similar protocol has been tested and
showed good results (see appendix B), al-
though it must be noted that the sample size
in that study was relatively small. Still, given
prior research establishing empirical support
for ACT treatment for a wide variety of psy-
chological problems (Ruiz, 2010), we feel
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that this protocol, if conducted with sensitiv-


ity and flexibility, will be beneficial for most
clients.
We’ve provided guidance on the amount
of time to spend on each procedure in each
session. However, these are only rough
guidelines. Depending on the group, you
may need to devote more or less time to par-
ticular procedures. If a session runs long and
you can’t fit everything in, simply cover the
remaining elements in the next session. The
last two sessions aren’t as full and therefore
provide flexibility at the end of the protocol.
Session 1
Session 1 begins with a brief mindfulness
practice to help group members begin cultiv-
ating this important skill. Most of the session
is dedicated to psychoeducation about the
ten schemas with the greatest impact on in-
terpersonal relationships and associated
schema coping behaviors. The session also
includes whiteboard exercises to facilitate
group discussion and exploration of these
topics.

Procedures

1. Administer a pre-treatment assess-


ment (such as the Young Schema
Questionnaire; see appendix A) and
any outcome measures you’d like to
use.
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2. Guide the group in a mindfulness


practice (Mindful Focusing or the Five
Senses Exercise; 5 minutes).

3. Provide psychoeducation on schemas


(Ten Key Schemas handout; 20
minutes).

4. Conduct a whiteboard exercise ex-


ploring why schemas are so powerful
(15 to 20 minutes).

5. Provide psychoeducation on typical


schema coping behaviors (Ten Com-
mon Schema Coping Behaviors
handout and monster at a party
metaphor; 20 minutes).

6. Conduct a whiteboard exercise ex-


ploring how schemas affect clients
emotionally and cognitively (20
minutes).

7. Assign homework (5 minutes).


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1. Administer a Pre-Treatment
Assessment
Have clients fill out a schema question-
naire before the session. (We recommend
the Young Schema Questionnaire, which you
can purchase at schematherapy.com; see ap-
pendix A for an example.) The schema ques-
tionnaire is used to identify members’
schemas, not as an assessment measure. The
purpose is to identify which schemas are
most salient for each member. Group mem-
bers can then choose which schemas reson-
ate with them the most and which they
would like to focus on. Also administer any
outcome measures you’d like to use, such as
the Valued Living Questionnaire (VLQ;
Wilson, Sandoz, Kitchens, & Roberts, 2010),
the Automatic Thoughts Questionnaire
(ATQ; Hollon & Kendall, 1980), the Accept-
ance and Action Questionnaire–II (AAQ-II;
Bond et al., 2011), or the Inventory of
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Interpersonal Problems (IIP-64; Horowitz et


al., 2000).

2. Lead a Mindfulness Practice


Guide the group in a brief mindfulness
practice: either Mindful Focusing or the Five
Senses Exercise (see chapter 4).

3. Provide Psychoeducation on
Schemas
Give the group members their results
from the schema questionnaire you admin-
istered, along with the handout Ten Key
Schemas. Have members circle the three
schemas where they scored highest and ask
them whether these schemas seem to correl-
ate with their experience. Then discuss the
concept of schemas and how they arise.
Here’s a script showing how you might do so:
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A maladaptive schema is essentially


a belief about yourself and your rela-
tionship to the world. It creates a
feeling that something is wrong with
you, your relationships, or the world
at large. Schemas are formed in
childhood and develop as a result of
ongoing dysfunctional experiences
with parents, siblings, and peers dur-
ing childhood, and they continue to
grow as children try to make sense of
their experience and avoid further
pain. Schemas come from repeated
toxic messages that we get about
ourselves from our early experiences,
such as “You’re bad” or “You can’t do
anything right,” or from specific
traumatic events. Once a schema is
formed, it’s extremely stable and be-
comes an enduring pattern that is re-
peated throughout your life.
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Schemas are like sunglasses that


distort all of your experiences. They
color the way you see things, and
they make assumptions and predic-
tions that tell you the schema is true
or will turn out to be true. Schemas
formed during childhood are
triggered repeatedly throughout
your adult life. Common triggers in-
clude stressful interpersonal events
and difficult thoughts and feelings.
Once a schema is triggered, it brings
up powerful automatic thoughts and
feelings about yourself that can lead
to depression, panic, loneliness, an-
ger, conflict, inadequate work per-
formance, addiction, and poor de-
cision making. Schemas interfere
with the ability to feel safe in rela-
tionships, to get your needs met, and
to meet the needs of others.
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Ten Key Schemas

Psychologist Jeffrey Young has identified


eighteen early maladaptive schemas. Ten
of these schemas have significant relev-
ance to interpersonal relationships. A
schema is a core belief. Core beliefs
define who we are and direct how we live
our lives. They create the internal mono-
logue that characterizes the thoughts, as-
sumptions, and interpretations that in-
form each person’s individual worldview.
When a schema is activated, it produces
intense emotions. Identifying your
schemas and examining how they impact
your life and your interactions with others
is essential to making positive changes in
your relationships. Study this list of the
ten schemas relevant to problems in in-
terpersonal relationships and keep it
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handy so you can identify which schemas


are affecting your interactions:

Abandonment and instability: the


belief that significant people in your
life are unstable or unreliable

Mistrust and abuse: the expecta-


tion that you will be harmed through
abuse or neglect

Emotional deprivation: the expect-


ation that your needs for emotional
support won’t be met, which may
take several forms:

• Deprivation of nurturance:
the absence of attention

Deprivation of empathy:
the absence of
understanding
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Deprivation of protection:
the absence of guidance

Defectiveness and shame: the be-


lief that you are defective, inferior,
or unlovable

Social isolation and alienation:


the belief that you don’t belong to a
group, are isolated, or are radically
different from others

Dependence and incompetence:


the belief that you are incapable or
helpless and require significant as-
sistance from others, that you can-
not survive without a certain person,
or both

Failure: the belief that you are inad-


equate or incompetent and will ulti-
mately fail
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Entitlement: the belief that you de-


serve privileges and are superior to
others

Subjugation: voluntarily meeting


the needs of others at the expense of
your own needs, submitting to others
to avoid real or perceived con-
sequences, or surrendering control to
others due to real or perceived
coercion

Unrelenting standards and hy-


percriticalness: the belief that you
must meet very high internalized
standards to avoid criticism, leading
to impairment in areas of life such as
pleasure, health, and satisfying
relationships

4. Explore Why Schemas Are So


Powerful
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Discuss clients’ specific schemas and


what makes them so powerful and hard to
change. List ideas from the group on the
whiteboard. Possible reasons include the
power of core beliefs, how intractable old
habits can be, that schemas predict the fu-
ture and therefore help us feel safe, that
schemas are self-perpetuating, that they are
experienced as truths about ourselves, or
that they bring up a lot of strong emotions
and thoughts.

5. Provide Psychoeducation on
Schema Coping Behaviors
Take some time to explain schema coping
behaviors (SCBs), perhaps starting with the
metaphor of a popcorn machine to illumin-
ate how thoughts are generated spontan-
eously and continuously:
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The mind is a popcorn machine,


eternally popping up thoughts and
judgments connected to our schemas
and pulling us to use old, habitual
ways of responding to the associated
pain. When a schema is triggered, we
tend to respond with behaviors that
attempt to control or block the pain
connected to the schema. I’ll refer to
these as schema coping behaviors.
Once a schema is triggered, we want
desperately to get rid of the thoughts
and feelings that come with it, such
as shame, fear, rejection, or hurt. We
tend to use one or more of three
broad strategies to attempt to get rid
of our schema-related pain: attack,
surrender, and avoidance. Here’s a
handout that outlines ten common
schema coping behaviors that tend to
be most damaging to relationships.
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Give group members the handout Ten


Common Schema Coping Behaviors (based
on Young et al., 2003). After reviewing these
common coping behaviors, begin to address
the costs of these behaviors, along with the
importance of willingness to have difficult
private experiences that come up when enga-
ging in valued actions.

Ten Common Schema


Coping Behaviors

Overcompensation

Aggression or hostility: If you use


this coping behavior in response to a
schema-triggering event, you’ll find
yourself counterattacking by
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blaming, criticizing, challenging, or


being resistant.

Dominance or excessive self-as-


sertion: If you use this coping beha-
vior in response to a schema-trigger-
ing event, you’ll find yourself trying
to control others in order to accom-
plish your goals.

Recognition seeking or status


seeking: If you use this coping be-
havior in response to a schema-trig-
gering event, you’ll find yourself
overcompensating by trying to im-
press others and get attention
through high achievement and
status.

Manipulation or exploitation: If
you use this coping behavior in re-
sponse to a schema-triggering event,
you’ll find yourself trying to meet
your own needs without letting
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others know what you’re doing. This


may involve the use of seduction or
not being completely truthful to
others.

Passive-aggressiveness or rebel-
lion: If you use this coping behavior
in response to a schema-triggering
event, you’ll appear to be compliant
but will rebel by procrastinating,
complaining, being tardy, pouting, or
performing poorly.

Surrender

Compliance or dependence: If you


use this coping behavior in response
to a schema-triggering event, you’ll
find yourself relying on others, giving
in, being dependent, behaving pass-
ively, avoiding conflict, and trying to
please others.
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Avoidance

Social withdrawal or excessive


autonomy: If you use this coping
behavior in response to a schema-
triggering event, you’ll find yourself
isolating socially, disconnecting, and
withdrawing from others. You may
appear to be excessively independ-
ent and self-reliant, or you may en-
gage in solitary activities such as
reading, watching TV, computer use,
or solitary work.

Compulsive stimulation seeking:


If you use this coping behavior in re-
sponse to a schema-triggering event,
you’ll find yourself seeking excite-
ment or distraction through compuls-
ive shopping, sex, gambling, risk
taking, or physical activity.

Addictive self-soothing: If you use


this coping behavior in response to a
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schema-triggering event, you’ll find


yourself seeking excitement with
drugs, alcohol, food, or excessive
self-stimulation.

Psychological withdrawal: If you


use this coping behavior in response
to a schema-triggering event, you’ll
find yourself escaping through disso-
ciation, denial, fantasy, or other in-
ternal forms of withdrawal.

The metaphor of a monster at a party


(similar to Joe the Bum in Hayes et al., 1999)
can be useful here. When working with this
metaphor, invite group members to think
about their own coping behaviors and share
what they would do at the party if their
schema was activated. This metaphor is in-
tended to be used interactively, not just as a
didactic device:
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To give an example of how the


thoughts and feelings that come with
a schema can cause you to use un-
helpful coping strategies, and to help
you understand how your struggle to
avoid the pain of a schema may lead
you to behave in a way that actually
exacerbates the schema, think of
schemas as loud, obnoxious mon-
sters. Imagine that you’re throwing a
party—the biggest party you’ve ever
hosted, and you’re extremely excited
about it. You send out invitations
saying that everyone is invited to the
party.
This party is extremely important
for you. You want it to be a huge suc-
cess. So, not surprisingly, your fail-
ure schema shows up at the party
and tells you, “This party is horrible.
The guests aren’t going to enjoy
themselves. No one will want to come
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to any of your parties again. The


food is terrible. The music is terrible.
You can’t get anything right. People
look bored.” You try to get rid of your
failure schema. You try to close the
door in his face, but he pushes his
way in. You try to wrestle him out the
door, but he fights back and the two
of you make a huge commotion. And
the more you fight, the less your
guests are enjoying themselves.
You might try to disprove your
failure schema by seeking reassur-
ance and asking everybody at the
party if they’re having a good time, if
they’re bored, if they like the music, if
they need anything, if the food is
okay. You might try to avoid your
failure schema by withdrawing or
keeping busy with trying to make
sure everything is perfect. You might
buy into your failure schema’s ideas
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that people are having a bad time


and behave in a defensive or attack-
ing way, saying things to your guests
like “You never enjoy my parties. You
never dance at any of my parties.
You always complain about my cook-
ing. I wouldn’t do this at one of your
parties.” You might decide to sur-
render completely, isolating yourself
in your bedroom and giving up on
the whole party.
You wanted to have a good time
at the party, but you’re so preoccu-
pied with avoiding your schema and
trying to get rid of him that you
haven’t been able to enjoy yourself.
But what if this schema-related pain
is unavoidable? What if it will always
show up under certain circum-
stances? What if every time you try
to do something that’s important to
you, like pull your life together, go to
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a job interview, have a loving rela-


tionship, or throw a fantastic party,
this pain is going to show up? Could
you be willing to allow your schema
of failure, defectiveness, abandon-
ment, or whatever to simply be there
as you do something you value, like
being present for and enjoying your
party? Could you be willing to have
all of the feelings and thoughts that
come with your schema and still be
engaged and present at the party
without struggling against it? Would
you be willing to learn to relate to
your schema in a different
way—maybe invite him in, keep some
distance from him, observe him, and
know that you can choose whether or
not to let him impact your behavior?
Can you recall a time when schema
thoughts and feelings tried to stop
439/611

you from doing something import-


ant, but you did it anyway?

6. Explore How Schemas Affect Clients


Emotionally and Cognitively
Guide the group in exploring how schem-
as affect them emotionally and cognitively.
What emotions and thoughts typically ac-
company each schema? List the ten key
schemas on the whiteboard and have group
members identify thoughts and feelings that
come up when particular schemas are activ-
ated. List the relevant emotions and
thoughts next to each schema. Using the
handout Ten Common Schema Coping Beha-
viors, have group members identify the
schema coping strategies they most often use
to avoid their schema-related pain. Explore
the outcome of using a particular schema
coping behavior when a schema is triggered.
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7. Assign Homework
Educate group members about the im-
portance of following through with home-
work assignments and explain that home-
work is a core mechanism for promoting
change and making progress in therapy.
Homework provides clients with an oppor-
tunity to practice new skills in their relation-
ships and explore workability. Then assign
the following homework to group members
to be practiced throughout the week:

▪ Ask clients to notice when schemas


are triggered and identify which
schema has been activated. Have
them observe what happened to
trigger the schema and note any
reactions or urges to react.

▪ Do at least three minutes of Mind-


ful Focusing every day.
Session 2
Session 2 also begins with a brief mindful-
ness practice to help group members contin-
ue cultivating this skill. The focus of this ses-
sion is on cultivating creative hopelessness
(Hayes et al., 1999). This is accomplished by
examining group members’ typical schema
coping behaviors and assessing their costs
and effectiveness. In addition, by exploring
their schema triggers and schema-related
thoughts, feelings, and coping behaviors, cli-
ents are also developing more awareness of
signals that can alert them to when their
schemas have been triggered, which can
eventually lead to responding to these events
more mindfully.

Procedures
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1. Guide the group in a mindfulness


practice (Mindful Focusing or the Five
Senses Exercise; 5 minutes).

2. Review group members’ experiences


with the homework from session 1
(15 to 20 minutes).

3. Explore schema triggers, coping be-


haviors, and outcomes through a
whiteboard exercise (Schema Trig-
gers, Thoughts, Feelings, and Coping
Behaviors Worksheet; 40 minutes).

4. Conduct a whiteboard exercise ex-


ploring creative hopelessness (20
minutes).

5. Assign homework (5 minutes).

1. Lead a Mindfulness Practice


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Guide the group in a brief mindfulness


practice: either Mindful Focusing or the Five
Senses Exercise (see chapter 4).

2. Review Homework
Ask group members to share what they
noticed when their schemas were triggered
over the past week.

3. Explore Schema Triggers, Coping


Behaviors, and Outcomes
Briefly review what schema coping beha-
viors are, then explain how they arise:

As we talked about in the previous


session, schema coping behaviors are
responses aimed at blocking or
controlling schema-related pain.
These coping behaviors may offer
temporary relief in the moment, but
444/611

in the long run they contribute to the


schema, make it feel more true, and
actually increase schema-related
emotional pain.
You may wonder where these un-
helpful behaviors come from. We
learn them by watching our parents
and other family members deal with
pain. Dad may have gotten angry
and gone on the attack when he was
hurt. Mom may have collapsed and
given up. A sister may have with-
drawn in her bedroom. A brother
may have started to drink.
In addition, sometimes we come
up with schema coping behaviors on
our own. When a schema is
triggered, we may stumble upon a
way of responding that feels like it of-
fers some relief from the emotional
pain. Because it seems to work, at
least temporarily, we stick with it,
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doing the same thing again and


again in similar situations.
The trouble with schema coping
behaviors is that they tend to hurt
other people, relationships, and, ulti-
mately, the person who’s using them.
Our relationships stop feeling good to
the people who are important to us.
After a while they may give up on us
or harden and withdraw. So, al-
though schema coping behaviors
may offer some temporary relief, in
the long run they make us feel worse
about ourselves—and may cause us
to lose people we love.

Introduce the six domains of interperson-


al relationships: work, friends, family, intim-
ate relationships, parenting, and community.
Then hand out the Schema Triggers,
Thoughts, Feelings, and Coping Behaviors
Worksheet.
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Ask group members to think of the


schema that most affects them and then
write it at the top of the worksheet. Alternat-
ively, you can have them write down differ-
ent schemas for various domains. For ex-
ample in the work domain, a failure schema
may be most relevant, and for intimate rela-
tionships, abandonment may be a bigger is-
sue. Next, ask them to consider what triggers
the schema in each relevant domain of rela-
tionships. Spend a few minutes discussing
such triggers as criticism, anger, withdrawal,
and demands from others, and feeling close,
vulnerable, or jealous. Work with one group
member to list his or her triggers in each rel-
evant domain on the whiteboard and have
the other group members list their own trig-
gers on their worksheets as you do so.
Have group members recall incidents
when their schemas were triggered, then ask
them to try to identify thoughts and feelings
that tend to be connected with particular
447/611

schemas. Help them get very specific and


come up with as many thoughts and feelings
as they can, then have them list those
thoughts and feelings on the worksheet.
Next, explore schema coping behaviors
with a few questions:

When your schema gets triggered,


what do you do? For example, if you
have a defectiveness schema, how do
you cope when you get criticized?
What do you do to deal with the
shame or hurt?
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Again, work with one group member and


list his or her coping behaviors on the white-
board and have the other group members list
their own schema coping behaviors on their
worksheets as you do so. Discuss what hap-
pens when they use an SCB and how this is
working for them. Get specific by exploring
the outcomes of one group member’s schema
coping behaviors in a particular relationship.
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Long-term, did the relationship get better or


worse? Long-term, did the client feel better
or worse? Explore schema maintenance and
the way the coping behaviors maintain, con-
tribute to, and exacerbate the schema-re-
lated pain. For example, you might point out
that the more we attempt to avoid being
abandoned by using such coping behaviors
as getting suspicious, accusing, and blaming,
the more likely we are to actually get aban-
doned, which maintains the abandonment
schema.

4. Explore Creative Hopelessness


Use the coping behaviors group members
identified on the Schema Triggers, Thoughts,
Feelings, and Coping Behaviors Worksheet
to begin working with creative hopelessness.
This key ACT strategy is very effective but
also challenging, so provide motivation by
exploring how effective old strategies have
450/611

been in reducing schema-related pain in the


long run:

Let’s write down all of the behaviors


that you’ve tried in an effort to get rid
of the painful feelings that come with
schemas. Since many of you have
identified a failure schema, let’s use
that for this exercise. What strategies
have you used to try to avoid feelings
of defectiveness, fear, hopelessness,
lack of self-worth, inadequacy, anxi-
ety, and so on?

As you list strategies on the whiteboard,


explore whether any of these techniques
have been successful in permanently elimin-
ating the pain. Continue exploring this and
writing down avoidant behaviors to get to
the underlying control strategies that group
members have used to avoid schema-related
pain:
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So here are all of these strategies that


you’ve been using to avoid this deep
pain. But what I’m hearing is that
none of them have actually worked to
get rid of it in the long run. You might
feel a little relief in the moment, but
over time, the pain gets worse. You’ve
put in so much effort, and for so long,
but that pain still comes back. You’ve
tried so many different strategies to
avoid this pain, and yet the problem
still remains. The struggle is still
there; the pain still shows up.
What if this pain is unavoidable?
What if this schema-related pain is
never going to go away? What if it’s
in you? Maybe the answer isn’t get-
ting rid of this pain. What if the an-
swer lies in the pain itself? What if
this familiar pain is going to have a
tendency to show up whenever you
take a step toward something
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meaningful in your relationships?


Maybe the answer lies in relating to
this pain in a different way: ob-
serving your schema, being curious
about it, and being willing to have it
come up when you’re about to do
something important and
meaningful.
What do we have control over?
What can we change? Can we change
our schemas and the thoughts and
feelings that come up when they’re
activated? Can we change our
schema coping behaviors?

5. Assign Homework
Assign the following homework to be
practiced throughout the week:

▪ Ask clients to watch for moments


when schemas are triggered, notice
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coping behaviors, and assess their


outcomes.

▪ They should do at least ten


minutes of Mindful Focusing every
day.
Session 3
As in sessions 1 and 2, begin with a brief
mindfulness exercise. This session continues
the work of exploring the outcomes of old
coping behaviors to establish that they aren’t
helpful in the long run. This work helps
group members arrive at creative hopeless-
ness, which must occur before proceeding
further with therapy, as it sets the stage for
trying something new.

Procedures

1. Guide the group in a mindfulness


practice (Mindful Focusing or the Five
Senses Exercise; 5 minutes).

2. Review group members’ experiences


with the homework from session 2
(15 to 20 minutes).
455/611

3. Explore the costs of schema coping


behaviors through a whiteboard ex-
ercise (Schema Coping Behavior Out-
comes Worksheet; 30 minutes).

4. Discuss creative hopelessness and


use such metaphors as quicksand
and digging a hole to help group
members grasp this key concept (20
minutes).

5. Help group members stop the


struggle for control using a visualiza-
tion based on a metaphor of the sky
and the weather (10 minutes).

6. Assign homework (5 minutes).

1. Lead a Mindfulness Practice


Guide the group in a brief mindfulness
practice: either Mindful Focusing or the Five
Senses Exercise (see chapter 4).
456/611

2. Review Homework
Ask group members to share moments
over the past week when their schemas were
triggered and to describe how they reacted.

3. Explore the Costs of Schema Coping


Behaviors
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Hand out the Schema Coping Behavior


Outcomes Worksheet and ask group mem-
bers to fill in what happens in each relevant
domain when they use their typical coping
behaviors, with a focus on the main out-
comes. Explain that the outcome of a coping
behavior is the effect it has on a particular
relationship and the other person in that re-
lationship. Ask clients to consider how the
relationship changes as a result of using that
coping behavior.
Work with one group member to list his
or her outcomes on the whiteboard and have
the other group members fill out their own
worksheets as you do so. Maintain a running
inquiry with the group member you’re work-
ing with directly, asking about his or her
sense of whether each outcome was positive
or negative. This discussion can help group
members see how maladaptive coping beha-
viors often exacerbate schemas, schema-
458/611

related feelings, and, ultimately, interperson-


al problems.

4. Discuss Creative Hopelessness


Understanding the costs of maladaptive
behaviors sets the stage for creative hope-
lessness—a painful but pivotal point where
group members discover new solutions and
commit to new, values-based behaviors. Be-
gin by asking the group to acknowledge the
costs. After they’ve responded, introduce the
term “creative hopelessness” and suggest
that the solution lies in accepting and facing
their pain:

Most of your efforts with these old


ways of coping with schemas seem to
result in more pain—for you and the
people you love. Is this true?
Creative hopelessness is the real-
ization that everything you’ve done to
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control and to minimize schema-re-


lated pain hasn’t worked, and that, if
anything, these efforts have made the
pain worse. Now that you know your
old coping behaviors have created
more pain, you can think about al-
ternative solutions. If running from
and avoiding schema-related pain
hasn’t worked, perhaps the answer is
to stop running. Perhaps the answer
lies in the pain itself. What if facing
and accepting the fear, shame, or
hurt connected to your schemas is the
answer?

Group members may remain attached to


avoidance as a strategy or have difficulty ac-
cepting the basic premise that avoidance
only leads to more pain. You might try to ex-
plain this dynamic didactically:
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The problem with struggling with


our thoughts and feelings is that the
more we struggle, the stronger these
thoughts and feelings become. The
more we try to avoid pain, the
stronger the pain becomes.

Metaphors can be useful here. Use the


quicksand metaphor (Hayes & Smith, 2005)
and possibly also the metaphor of digging a
hole (Hayes et al., 1999), both described in
chapter 4, to illustrate the concept. After
presenting the metaphors, explore group
members’ thoughts as follows and list their
responses on the whiteboard:

What are the costs of struggling in


quicksand and trying to make painful
thoughts and feelings go away? What
are the interpersonal and emotional
costs?
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5. Help Group Members Stop the


Struggle for Control
The simple yet profound metaphor of
how the sky holds the weather (Harris,
2009) can help group members see that
painful experiences are transitory, which can
help them let go of the struggle to control
their experience. It can also open the door to
developing the observer-self perspective.
Here’s a script for a visualization based on
the metaphor of the sky and the weather:

So, if struggling and trying to control


your thoughts, feelings, and internal
experiences doesn’t work, what can
you do? I’d like to guide you in a visu-
alization that will help you see how
you can relate to them differently. If
you’re willing, close your eyes, then
pay close attention to your breath,
feeling the air going in and out of
your nostrils. Feel your feet on the
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floor. Get in touch with where you


are right now, in this moment.
Now imagine that you are the sky.
The sky is always there, holding the
constantly changing weather. The
weather is sometimes cloudy and
dark, sometimes snowy, sometimes
rainy, and sometimes sunny, with a
gentle breeze and fluffy white clouds.
As wind, storms, rain, and sunshine
come and go, the sky is always there,
just receiving each change of weather
with perfect willingness. The sky isn’t
invested in what the weather should
be. Difficult thoughts and emotions
also come and go, just like sunny and
cloudy days.
Having different weather is neces-
sary in life. You wouldn’t take the
same delight in a beautiful sunny day
if every day was bright and blue. We
need rain to supply water. Similarly,
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we need our pain to let us know when


we’re off track or have lost sight of
what’s important.
Do you think you could just ob-
serve and have all of your weather,
without trying to change or struggle
with it? Could you simply observe the
sensations in your body, the thoughts
going through your head, and your
emotions? Sometimes you’re sad, and
sometimes you’re happy. Sometimes
you’re insecure, and sometimes
you’re confident. Would you be will-
ing to just notice all of your experi-
ences as they unfold, moment by
moment?
Being the sky is like being an ob-
server of your experience. The ob-
server self is clear and boundless and
always willing to simply hold passing
experiences, just like the sky. The ob-
server self is a place from which you
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can have all of your experiences


without resisting or wrestling with
them. It’s also a place from which you
can choose actions that are consistent
with the kind of person you want to
be in your relationships.
To the observer self, thoughts and
emotions are like the weather, ever
passing, ever changing. Difficult
thoughts and emotions, including
those triggered by your schemas, are
like terrible, scary storms with thun-
der, lightning, and howling wind.
Eventually, the storm quiets and the
air clears. There are storms in the
sky. That’s unavoidable; it’s just part
of the weather. When we learn to
stop struggling with our weather and
instead simply observe it mindfully,
we can begin to notice that painful
thoughts and emotions come and go,
just like the weather in the sky.
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6. Assign Homework
Assign the following homework to be
practiced throughout the week:

▪ Ask group members to watch for


their two most powerful schemas
throughout the next week, watch-
ing for them in conversations and
other interactions. Remind them
that painful emotions, such as an-
ger, sadness, or shame, can serve
as red flags that their schemas
have been activated. As they watch
their experience, have them notice
the moment when they’re tempted
to use old coping behaviors. Identi-
fy this as “the moment of choice”:
the point where they have the op-
tion to do something different,
even if they aren’t yet able to do so.
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▪ Have them do at least ten minutes


of Mindful Focusing every day.
Session 4
Once again, begin with a brief mindfulness
exercise to help group members continue to
develop this skill. In this session, the focus
turns to values. Various worksheets and ex-
ercises are employed to help group members
clarify their values, develop values-based in-
tentions, and identify barriers to valued ac-
tion. A role play based on the metaphor of
monsters on the bus (Hayes & Smith, 2005)
is used to help group members find new
ways of relating to perceived barriers.

Procedures

1. Guide the group in a mindfulness


practice (Mindful Focusing or the Five
Senses Exercise; 5 minutes).
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2. Review group members’ experiences


with the homework from session 3
(10 minutes).

3. Provide psychoeducation on values


(10 to 15 minutes).

4. Assist group members in clarifying


values and identifying valued inten-
tions (Valued Intentions Worksheet;
25 to 30 minutes).

5. Explore obstacles to valued action


(Assessing Barriers Worksheet; 15 to
20 minutes).

6. Conduct a role-playing experiential


exercise based on the monsters on
the bus metaphor (10 to 15
minutes).

7. Assign homework (5 minutes).

1. Lead a Mindfulness Practice


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Guide the group in a brief mindfulness


practice: either Mindful Focusing or the Five
Senses Exercise (see chapter 4).

2. Review Homework
Ask group members to share their experi-
ence in watching for the moment of choice.
Ask whether they were able to notice when
their schemas were activated and any associ-
ated urges to engage in old coping behaviors.
Also ask whether they were able to identify
this as the moment of choice.

3. Provide Psychoeducation on Values


Before beginning the work of clarifying
values and identifying values-based inten-
tions, explain values from the ACT perspect-
ive. Be sure to address that values are freely
chosen and personal and to establish the
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distinction between values and goals. Here’s


a sample script (based on Vuille, 2006b):

As we’ve discussed in previous ses-


sions, problematic old coping behavi-
ors are having a big impact on your
relationships. But it doesn’t have to
be that way. There are ways you’d
rather be and rather act—ways based
on deep values—that could make
your relationships feel much better.
Choosing the direction you want to
go in your life is similar to being the
director of the movie of your life, ex-
cept that you have limited control.
You can only control the actor who’s
playing your role in the movie. You
can choose how that actor responds,
behaves, talks, and acts, but you can’t
control any of the other actors or the
events taking place in the movie. But
you can have the actor playing your
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role behave exactly like the person


you want to be—your own ideal ver-
sion of yourself.
How would you want this actor to
relate to others and behave in rela-
tionships? What this boils down to is
what you want to stand for. This is
where you’ll find your deepest, most
meaningful values. As you start
thinking about your values, there are
a couple of things to keep in mind.
The first is that values are personal
and must be authentic. Think about
what really matters to you, not what
you think “should” matter, and not
what you think other people believe
you should value.
The second thing is that values
are different from goals. Values are
like a direction you want to travel in,
whereas goals are specific steps
along the way. A value reflects how
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you want to be. A goal, or intention,


is a specific action you can take in the
service of that value.

4. Clarify Values and Identify Valued


Intentions
Next, hand out the Valued Intentions
Worksheet, then introduce the six interper-
sonal domains. To help group members
identify their core values, you might ask
them to think about their own funeral or epi-
taph and how they’d like to be remembered
(Hayes et al., 1999):

In today’s session, we’re going to ex-


plore your core values. To learn more
about how you want to be in your re-
lationships, we’ll look at six domains
of relationships: work relationships,
friendships, family relationships,
partner relationships, parenting, and
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community relationships. For each


domain that’s relevant to you, identi-
fy at least one core value about how
you’d like to be—how you’d like to in-
teract with others in those relation-
ships. Imagine that you are at your
own funeral; imagine you are hear-
ing your own eulogy. What would
you like people to say about you?
What kind of person would you like
to be? How would you want to be
remembered?
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Working with one group member at the


whiteboard to exemplify the process, ask
group members to assign a rating of import-
ance to each domain using a scale of 0 to 2,
where 0 means not important, 1 means mod-
erately important, and 2 means very import-
ant. Next, ask them to select one of the do-
mains with the highest rating to work on in
this session. Then have them identify one or
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two key values in regard to relationships in


that domain. Explain that the group will con-
tinue to work on values in all remaining ses-
sions, so they’ll have a chance to work on
other domains in upcoming sessions.
The next step is to convert these general
values into specific behavioral intentions,
which are essentially goals, as described
above. For example, how, exactly, would a
group member turn the parenting value “giv-
ing my children the experience of being
loved” into action? Specific intentions might
include “Spend ten minutes on Thursday
night reading to them” or “Spend ten
minutes Thursday night asking them how
their day went or how their friends are do-
ing.” Generating specific intentions allows
group members to develop a targeted plan
for behavioral change based on their values.
Explain that the group will also continue to
work on valued intentions in all remaining
sessions, that you’ll ask them to identify and
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commit to one intention each week from this


point forward, and that therefore they need
not begin with something highly challenging.
If time allows, you can have the group
clarify values and identify valued intentions
in several domains. If group members have
listed several intentions, ask them to rate the
importance of their each intention on a scale
from 1 to 10, where 1 means it hardly matters
and 10 means it’s of the greatest importance.
Before moving on, ask group members to se-
lect an intention that they are willing to com-
mit to acting on over the next week.

5. Explore Obstacles to Valued Action


Next, ask group members to envision act-
ing on this intention. Hand out the Assessing
Barriers Worksheet. Work with one group
member at the whiteboard and ask the rest
of the group to fill out the worksheet, listing
potential barriers to acting on the intention
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they’ve committed to. What emotions or


thoughts might get in the way?

6. Role-Play the Monsters on the Bus


Metaphor
As discussed in chapter 5, the monsters
on the bus metaphor (Hayes & Smith, 2005)
is an excellent way to help clients work with
barriers. In group therapy, you can have the
group role-play the metaphor. Have each
member focus on the intention they commit-
ted to for the week and on the barriers that
show up for them regarding this intention.
Ask one group member whether he or she
would be willing to come up to do an experi-
ential role play, or ask for a volunteer. Begin
to describe the metaphor to this client, along
these lines:
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Imagine that you’re a bus driver, and


that the bus is your life. You want to
steer toward your values and the
things that are important to you, but
there monsters that try to stop or di-
vert you. These monsters are your
barriers. They know your deepest in-
securities and know exactly what to
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say to stop you from going in the dir-


ection you want to go.

Ask six other group members whether


they’d be willing to come forward and parti-
cipate. Assign each of the six a specific
thought, feeling, or memory from the first
member’s list of barriers, then have them
role-play the monsters while the first client
attempts to drive toward her or his value.
Have these seven group members act out
the scenario, with the first member trying to
go toward a specific intention as the mon-
sters keep showing up in front of the bus.
Ask the driver what he or she would like to
do about the monsters. Drivers will probably
try a number of different strategies, such as
trying to run over the monsters, bargaining
with them, and threatening them. As the role
play continues, help the driver see that these
strategies aren’t working and haven’t been
working. Ask the driver what he or she might
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do differently. If the driver doesn’t come up


with the option of letting the monsters onto
the bus, ask the group for suggestions. Typic-
ally, a group member will eventually come
up with this option. If no one in the group
suggests the option of bringing the monsters
onto the bus, eventually suggest this as an
option that allows for more freedom to travel
in valued directions.

7. Assign Homework
Assign the following homework to be
practiced throughout the week:

▪ Ask group members to commit to


following through on one intention
throughout the next week. When
schemas are activated and present
barriers to acting on that intention,
notice the moment of choice and
persist in the valued behavior
anyway.
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▪ Have them do at least ten minutes


of Mindful Focusing every day.
Session 5
Again, begin with a brief mindfulness exer-
cise to help group members continue to de-
velop this skill. In this session, the focus
turns to cognitive defusion. Metaphors are
used to illustrate how schema-related
thoughts can serve as barriers to values-
based action and how the mind is continu-
ously generating thoughts. The rest of the
session is devoted to explaining specific de-
fusion techniques and practicing a few of
them in session. Several of these techniques
may also be helpful with emotions and other
private experiences.

Procedures

1. Guide the group in a mindfulness


practice (Mindful Focusing or the Five
Senses Exercise; 5 minutes).
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2. Review group members’ experiences


with the homework from session 4
and set a new intention for the com-
ing week (Valued Intentions Work-
sheet; 15 to 20 minutes).

3. Provide psychoeducation on defusion


(monsters on the bus and sales rep-
resentative metaphors and Assessing
Barriers Worksheet; 10 to 15
minutes).

4. Teach specific defusion techniques


(Defusion Skills handout; 10 to 15
minutes).

5. Have group members practice defu-


sion techniques in session (visualiza-
tion of putting thoughts on clouds,
objectifying, and role-playing a
group member’s mind and schema
thoughts; 25 minutes).

6. Assign homework (5 to 15 minutes).


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1. Lead a Mindfulness Practice


Guide the group in a brief mindfulness
practice: either Mindful Focusing or the Five
Senses Exercise (see chapter 4).

2. Review Homework
Ask group members to share their experi-
ence in following through on their valued in-
tention. Ask whether they were able to notice
the moment of choice. Explore any barriers
that came up and brainstorm strategies to
deal with those barriers, then have them set
a new intention for the following week. For
those who didn’t follow through, it’s best to
continue working on the previously identi-
fied intention unless they have determined
that the intention doesn’t genuinely reflect
their values.
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3. Provide Psychoeducation on
Defusion
Begin by explaining that this session will
continue the work of exploring values. Re-
mind the group that thoughts and feelings
can function as barriers to valued action and
that in order to change how they interact
with others, they may need to learn to relate
to their internal experiences differently. Use
the monsters on the bus metaphor to explore
the idea of relating to thoughts differently.
The sales representative metaphor from
chapter 6 (Vuille, 2006a) can also be helpful.
Here’s an example of how you can weave
these two metaphors together to set the stage
for defusion:

Let’s revisit that metaphor of mon-


sters on the bus, from the end of the
previous session. What do you do
when you’re driving your bus in a
certain direction and those monsters
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pop up and try to stop you or make


you turn around? How can you re-
late to these monsters in a way that
keeps you in control of the direction
you’re traveling? The human mind
has a tendency to be full of these
monsters, and some of them are
thoughts that keep popping up and
trying to stop us from going toward
our destination. If you buy into these
thoughts, they can become real barri-
ers. But you can also notice that they
aren’t real monsters—that they’re just
part of the same old schema thoughts
that the mind seems to be so fond of
producing.
In a way, these thoughts are like
sales representatives. They push their
way in and try to sell you a bunch of
products that you really don’t want.
Some of these thoughts are persistent
and relentless, and if you buy one
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product, they’ll continue throwing


more and more products at you.
Some products aren’t very enticing
and are easier to resist, but those
schema-driven thoughts seem so true
that it’s hard not to buy into them.
So how can you relate to these
sales representatives differently? In-
stead of buying the thoughts they of-
fer or trying to explain why you don’t
want to buy them, you can let those
pushy sales representatives into your
house, look at what they’re offering,
and then say, “Thank you for all of
these products that you’re offering to
sell me, but I’m not interested in buy-
ing any of them.”
Look at your Assessing Barriers
Worksheet. Which of the schema-re-
lated thoughts that you listed are
really good sales representatives?
Which of these thoughts do you buy
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often? Let’s practice noticing what


they’re trying to sell you, like “I’m
never going to hold a job,” “If people
really knew me, they wouldn’t like
me,” “People just use me,” or “I’m go-
ing to mess everything up.” Then
thank the sales representative for the
offer and say you aren’t interested in
buying that product.

Take some time to establish that the


mind tends to generate thoughts near con-
stantly and that we have very little control
over their frequency or content. The meta-
phor of the popcorn machine, first intro-
duced in session 1, can be helpful here:

Notice that many of the random


thoughts your mind throws at you
aren’t very helpful. Like those mon-
sters, they block your path. They keep
you stuck by pulling you to use old
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coping strategies that are ineffective


or even damaging. Like we discussed
before, the mind can be like a pop-
corn machine. It’s constantly throw-
ing thoughts at you, whether you like
it or not. Stories, evaluations, reas-
ons, and judgments keep coming, and
you can’t stop them, can you? So
who’s in charge, you or your mind?
Can you stop your mind from pop-
ping thoughts? Can you choose the
thoughts your mind pops?
Thoughts include explanations for
what’s going on, old stories about
why things happened, and problem
solving to try to figure out how to
eliminate pain. They also include
judgment—lots and lots of judgment.
Notice that many of the reasons and
explanations that your mind throws
at you are just stories that tell you
your schemas are true and give you
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rules about how you can avoid


schema-related pain. So how can you
relate to your mind differently? How
can you gain some distance from the
thoughts that keep popping in your
head? How can you free yourself
from schema-related thoughts? The
answer lies in practicing observing
your thoughts, as well as your feel-
ings, sensations, and urges, from a
distance—disentangling from them
and simply having them, like the sky
has the weather. Then you can notice
them without struggling with them,
which will increase your ability to
notice those moments of choice when
you have the option to behave
differently.

4. Teach Specific Defusion Techniques


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Give group members the Defusion Skills


handout and briefly explain defusion:

This handout lists things that you can


do to help you observe your thoughts
from a little distance without getting
hooked into them or buying them, so
that you can be in control of your
destination and the direction you’re
steering your bus. These techniques
are called defusion skills. “Defusion”
may seem like an odd word, and it is
unusual. What it’s getting at is that
these skills help you become less fused
or entangled with particular
thoughts.

Briefly describe each technique using the


handout and provide instruction in several of
them. If you’re unfamiliar with any of these
techniques or would like more details, con-
sult chapter 6, which discusses many of
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them. (Also note that chapter 6 includes an


alternative Defusion Skills handout, which
lists more skills and doesn’t provide descrip-
tions of them. You can use whichever version
you prefer.)

Defusion Skills

1. Naming the mind. Give your mind


a name (other than your own name,
of course!).

2. Scheduling a time to worry, ob-


sess, ruminate, get angry, blame,
and so on. An example would be
“I’ll put this aside for now and worry
about what a failure I am at eight
o’clock tonight.”

3. Assigning descriptive labels to


whatever passes through your
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mind. As you observe your experi-


ence, you can simply acknowledge
and label your internal experience
with broad terms like “thought,”
“memory,” “desire,” “feeling,”
“urge,” “regret,” “yearning,”
“image,” “impulse,” “wish,” “plan,”
and “idea.”

4. Having (not being) your experi-


ences. You can use the phrase “I’m
having…” to help you separate your-
self from your experiences; for ex-
ample, “I’m having the thought
that…” “I’m having the evaluation
that…” “I’m having the sensation
that…” “I’m having the feeling that…”
“I’m having a thought that is
predicting…”

5. Labeling thoughts. When you no-


tice specific thoughts, labeling them
can help you let them go; for ex-
ample, “That was a ‘harsh’ thought,”
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“That was a ‘judgmental’ thought,”


That was a ‘prediction’ thought,”
“That was a ‘fear’ thought,” or “That
was a ‘self-hating’ thought.”

6. Thanking your mind. Sometimes


the mind will quiet down a bit if it
feels it’s been heard. Try thanking
your mind for its sometimes not-so-
helpful efforts to help you: “Thank
you, Mind, for that thought [judg-
ment, prediction, memory, or
whatever].” You can even use the
name you’ve come up with for your
mind or say you aren’t interested at
this time: “Thank you, Amanda, for
that thought, but I don’t want to buy
it right now.”

7. Repeating the thought out loud


in a silly voice. You can also sing
thoughts.
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8. Putting thoughts on clouds. You


can visualize putting your thoughts
on clouds and then watching them
drift away. Or you may prefer a dif-
ferent image, such as boxcars on a
train passing by, balloons floating
away in the sky, or leaves being car-
ried away on a stream.

9. Objectifying, or thinking of
thoughts as physical objects.
Imagine what physical characteristics
your thought might have—size, col-
or, texture, shape, density, consist-
ency, weight, flexibility, temperat-
ure, and so on. This technique is also
very useful for disentangling yourself
from emotions and other internal
experiences.

10. Physically letting go. As thoughts


arrive, rotate your hand so your
palm is facing down and imagine the
thought dropping out of sight.
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11. Card carrying. In this defusion


technique, you carry a card with you
and write down thought monsters as
they come up. Then, whenever these
painful cognitions recur, you can re-
mind yourself, “It’s on the card,” and
let it go.

5. Practice Defusion in Session


After reviewing all of the techniques,
practice a few of them in session. Putting
thoughts on clouds works well as a visualiza-
tion and is a good place to begin. Here’s a
script for guiding the group in this visualiza-
tion (Hayes, Strosahl, and Wilson, 1999):

Close your eyes and imagine that


clouds in the sky are drifting past in
front of you, one after another.
You’re simply sitting and watching
the clouds floating by. Notice that this
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takes no effort on your part. Your


awareness, in which these clouds are
floating, is very simple and effortless.
Now look at the thoughts arising
in your mind. You might notice vari-
ous images, concepts, desires, hopes,
fears, and more, all spontaneously
arising in your awareness. They rise
up, linger a bit, and pass. All you
need to do, if you are willing, is let
your mind think whatever thoughts it
is already thinking and then put each
thought or image on a cloud and
watch it drift away. Simply observe
as your thoughts drift by, one after
another. If you don’t like the image of
clouds, you can think of boxcars on a
passing train, balloons floating into
the sky, or leaves being carried away
by a stream. Whatever image you
use, put your thoughts, memories,
evaluations, judgments, and
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predictions on them and just watch


them flow away, one after another.
You can see the clouds float by be-
cause you are not those clouds; you
are the witness of those clouds. You
can feel bodily feelings because you
are not those feelings; you are the
witness of those feelings. You can see
thoughts float by because you are not
those thoughts; you are the witness of
those thoughts. Once you notice that
your mind has tricked you and you’ve
gotten caught up in thoughts rather
than putting them on clouds, con-
gratulate yourself for noticing that,
then just continue putting your
thoughts on the clouds and watching
them flow past, one after another. If
you find yourself thinking, “This isn’t
working,” “This is weird,” or “I’m not
doing this right,” just put that
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thought on a cloud too and watch it


float past.

Objectifying, or assigning physical qualit-


ies to thoughts (or emotions or any other in-
ternal experiences), lends itself to an in-ses-
sion exercise. Start by asking one group
member to focus on a typical schema-driven
feeling. Then ask him or her to imagine what
physical characteristics this thought would
have if it were an object within the body. Ask
about size, color, texture, shape, density,
consistency, weight, flexibility, temperature,
and so on. Then say that you’re going to take
the object out of the person. Act this out and
put the imaginary object in front of the
group member and ask him or her for any re-
actions to having this object standing in
front of him or her. Then objectify this reac-
tion in the same way.
Once the group is familiar with the vari-
ous defusion techniques, you can use a role-
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playing exercise to have them practice choos-


ing defusion techniques to use in the mo-
ment. Ask a group member to list about six
typical schema-driven thoughts and give
them to you. Then play the role of that per-
son’s mind, throwing those thoughts at the
person randomly. Have the person choose
defusion techniques from the handout in re-
sponse to the thoughts. If the client gets
stuck, ask other group members to make
suggestions. Here’s a dialogue showing how
this might play out. In this example, the cli-
ent has given her mind the name Amanda:
Therapist: Don’t share your feelings with
your boyfriend. If he really knew
you he would leave you.
Client: Thank you, Amanda, for that thought.
Therapist: He doesn’t get it. You don’t need
him; just keep your distance and he
won’t be able to hurt you.
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Client: I’m just going to notice that thought


and put it on a cloud.
Therapist: He’s going to leave you and you’re
never going to find anyone better
than him.
Client: I’m having the thought that I’ll never
find a better boyfriend than Bill.
Therapist: You need to think about how to
keep him from leaving you. Call him
and demand that he explain him-
self. If you don’t think about this
and figure it out, you’ll end up
alone.
Client: Thank you, Amanda, for that thought.
I’ll schedule a time to come back to
it. I’ll think about it tonight at eight
o’clock.
Therapist: If you don’t think about this right
now, you’re just going to continue
to get abandoned.
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Client: I’m having the sensation of my heart


beating really fast and the feeling of
anxiety.
After demonstrating this approach in
front of the group, have group members get
into pairs to continue practicing the exercise.
In each pair, one client acts as the mind,
reading from the other’s list of cognitive bar-
riers on the Assessing Barriers Worksheet,
and the second client practices responding
with various defusion techniques. After
about five minutes, have them switch roles.
Afterward, reconvene the group and have
everyone explore their reactions to the
exercise.

6. Assign Homework
Assign the following homework to be
practiced throughout the week:
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▪ Ask group members to commit to


following through on the valued in-
tention identified at the beginning
of the session and to using cognit-
ive defusion techniques from the
handout while engaging in com-
mitted actions.

▪ Ask that they do at least ten


minutes of Mindful Focusing every
day.

▪ Encourage group members to no-


tice a thought that’s a pushy sales
representative. What are the con-
sequences of believing this
thought? What are the con-
sequences of not believing it? What
are the pros and cons of believing
this thought?
Session 6
At this point, halfway through the ten-week
protocol, group members have probably
made significant strides in mindfulness.
Therefore, sessions 6 through 9 begin with a
review of homework (following through on
committed actions) and setting a new inten-
tion for the coming week. Session 6 focuses
primarily on defusion, and specifically on
evaluations and negative self-labels. The ses-
sion concludes with a visualization to help
group members begin to cultivate the
observer-self perspective.

Procedures

1. Review group members’ experiences


with the homework from session 5
and set a new intention for the
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coming week (Valued Intentions


Worksheet; 15 to 20 minutes).

2. Provide psychoeducation on defu-


sion, with a focus on evaluations
versus descriptions (evaluations as
prison bars and describing versus
evaluating a chair; 10 to 15
minutes).

3. Conduct an experiential exercise in


evaluations versus descriptions
(telling a story and noting evalu-
ations; 15 minutes).

4. Explore self-evaluations via discus-


sion and a whiteboard exercise (self-
evaluations being mood dependent;
20 to 25 minutes).

5. Cultivate self-as-context with an ex-


periential exercise and a visualization
(chessboard metaphor and worst self
visualization; 15 minutes).
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6. Assign homework (5 minutes).

1. Review Homework
Ask group members to share their experi-
ence in following through on their valued in-
tention. Explore any barriers that came up
and brainstorm strategies to deal with those
barriers, then have them set a new intention
for the following week. For those who didn’t
follow through, it’s best to continue working
on the previously identified intention unless
they have determined that the intention
doesn’t genuinely reflect their values.

2. Provide Psychoeducation on Evalu-


ations vs. Descriptions
Helping group members defuse from old
stories and labels about themselves is essen-
tial to helping them get some distance from
their schemas. You can start by assisting
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them in distinguishing between facts, which


exist in the world and can be tested, versus
evaluations, which are in us and are based on
our subjective reality.
Here’s a script (based on Ciarrochi &
Bailey, 2008, and Hayes et al., 1999) for
helping explain the distinction between eval-
uations and descriptions. You’ll need to
modify the description of the chair to match
a chair in the room that you use for the pur-
poses of this discussion:

We’ve been exploring your values


and looking at some of the thoughts
and feelings that trigger your schem-
as, as well as some of the thoughts
and feelings that act as barriers and
stop you from acting on your values.
A particularly problematic type of
thoughts is evaluations. They can
seem so powerful, and even though
they’re just opinions, they tend to feel
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real and true—so much so that they


can be like prison bars. But like all
other types of thoughts, they are just
products of the mind that come and
go. We can choose to buy into them
and let them hold us back, or we can
choose not to buy into them so we can
take steps in the directions we want
to go. As with the monsters on the
bus, we can bring those thoughts
with us to our destination. Thoughts,
feelings, predictions, and evaluations
connected to our schemas aren’t real.
They don’t exist in the external
world; they are inside of us. But
when you try to take steps toward
doing something that’s important to
you, they have a tendency to come up
and seem very real, and that can stop
you in your tracks.
Distinguishing between an evalu-
ation and a description is crucial
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because the mind would have us be-


lieve that our evaluations are actual
descriptions. It is useful to notice this
so we don’t fall into that mind trap.
Let’s take a look at what happens
when we use language to evaluate.
Consider the question “Would you
call this a good or a bad chair?”
People might answer with “This is a
good chair,” “This is a bad chair,” or
“This is a gorgeous chair.” These are
evaluations, but they sound just like
descriptions of the chair—just like
someone saying, “This is a wooden
chair,” “This is a brown chair,” or
“This is a chair that doesn’t recline.”
But can the evaluations really be con-
sidered descriptions? Is “This is a
good chair” the same type of state-
ment as “This is a wooden chair”?
The mind would have you believe so.
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Now, notice that if we were all to


leave this room and there were no
one here to evaluate the chair, it
would still be “a wooden chair,” “a
brown chair,” and “a chair that
doesn’t recline.” But it won’t be “a
good chair,” “a bad chair,” or “a gor-
geous chair” anymore. Our evalu-
ations are not descriptions of the
chair, or of any object or any person.
Our evaluations are within us. If
everybody in the world were to die
tomorrow, the chair would still be
wooden and brown, but it wouldn’t
be good or bad. Because of how lan-
guage works, the mind can obscure
the difference between an evaluation
and a description. Both kinds of
statements look the same: “This is a
such-and-such chair.” But if “good”
and “bad” are seen for what they
are—mere evaluations, and not
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descriptions as the mind says they


are—that makes a huge difference.
Evaluations aren’t real, like a color,
wood, or the mechanics of the chair.
They’re just ideas or opinions that ex-
ist in the mind. We don’t have to let
them control our behaviors. They are
just thoughts.

3. Conduct an Experiential Exercise in


Evaluations vs. Descriptions
Explain that everyone tends to engage in
evaluation much of the time; this is just how
the mind works. Then ask group members to
pair up and sit across from each other. Ex-
plain that the task is for one person in each
pair to tell a story—perhaps about a recent
event or interaction—for three minutes.
When the other person notices an evalu-
ation, he or she is simply to label it, saying
only “evaluation” in a neutral, almost
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scientific tone. The only word the listener is


allowed to say is “evaluation.” The speaker is
simply to continue talking, without changing
the subject to the listener’s observations. The
point is simply to gain some practice in noti-
cing when evaluations are occurring. After
three minutes, have speaker and listener
switch roles and repeat the exercise.
Afterward, have group members share
their experience without analysis or inter-
pretation. You might ask something like
“What was your experience of observing your
evaluations?” Then point out that group
members can use a similar approach with
their own evaluations and other thoughts, as
well as with physical sensations, emotions,
and impulses. You can also highlight how the
approach in the experiential exercise is simil-
ar to some of the defusion techniques
covered in session 5:
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Notice that you can do the same thing


with your own evaluations and other
thoughts, as well as with emotions,
impulses, and physical sensations.
You can say “emotion” when you no-
tice an emotion, or you can label spe-
cific emotions, saying, “That’s anger”
or “That’s shame,” or simply
“sadness.” It’s like noticing what’s go-
ing on with the weather: “Oh, it’s
raining” or “It’s warm.”

4. Explore Self-Evaluations
The work on evaluations helps set the
stage for exploring self-evaluations. You can
simply continue with the previous line of
thought and describe applying defusion tech-
niques to self-evaluations:

If you notice a thought like “I’m an


awful person,” you can name it for
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what it is using one of the defusion


techniques we talked about last time.
You can even add a description to
help distinguish the evaluation. With
“I’m an awful person,” you could first
describe yourself, saying, “I am a
person,” and then add “and I am hav-
ing the evaluation that I am awful.”
This sounds a bit weird, but that’s the
point. Because it’s odd, it disrupts the
normal language conditions that the
mind uses to trick us. So if you notice
that you’re evaluating yourself or
what you’re doing, or even evaluat-
ing your evaluations, simply note
that your mind has tricked you once
again and say, “Oh, there’s an evalu-
ation,” one more time.

Take some time to explain why self-eval-


uations are a particularly problematic type of
thought:
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Evaluations about ourselves are es-


pecially dangerous because they can
turn into labels about ourselves, who
we are, and how we “should” be. We
start putting ourselves in boxes that
limit our choices. Sometimes our la-
bels and self-evaluations come from
stories others have told us regarding
who we are and how we should be.
And while some of our self-evalu-
ations are positive, like “I’m a good
student,” “I’m intelligent,” “I’m beau-
tiful,” or “I’m funny,” some of them
are really negative, like “I’m ugly,”
“I’m stupid,” “I always fail,” or
“People always leave me.” These la-
bels can then lead to rules aimed at
maintaining our image of
ourselves—rules that tell us how we
“should” behave or interact with oth-
ers. But the truth is, our sense of self
and the stories we tell ourselves
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about ourselves are constantly chan-


ging. Depending on your mood or the
day, you may choose to buy into dif-
ferent stories and labels about
yourself.

Use this explanation to lead into a white-


board exercise exploring how group
members’ self-evaluations vary depending
on the context. Start by asking the group to
give examples of their typical self-evalu-
ations when they’re in a great mood or feel-
ing at their best. List a number of these, then
ask for examples of their typical self-evalu-
ations when they’re in a bad mood or feeling
at their worst.

5. Cultivate Self-as-Context
Work on defusing from self-evaluations
overlaps and leads naturally to cultivating
self-as-context, or the observer self. An
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experiential exercise using the metaphor of a


chessboard (and an actual chessboard) can
be useful here (Hayes et al., 1999). Ask for a
volunteer to come up and do the exercise.
Have the volunteer list ten positive self-eval-
uations on one piece of paper and ten
negative self-evaluations on another. Keep
the list of negative self-evaluations and give
the positive list to the volunteer. Sit facing
the volunteer with the chessboard between
you, then begin putting pieces on the board,
alternating between the two of you and stat-
ing one of the labels out loud each time.
Once all of the pieces have been placed,
suggest that the person isn’t any of the
pieces, or even either of the players. Help the
volunteer arrive at the realization that he or
she can be the chessboard, in contact with
thoughts, feelings, and other internal experi-
ences without being them. Here’s an ex-
ample of how you might do so:
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Some of these pieces are good, and


some are very painful. We humans
struggle to get rid of all these painful
thoughts and feelings that show up
when our schemas are activated.
There are moments when you feel in-
secure, and moments when you feel
very confident; moments when you
feel competent, and moments when
you feel like a failure. There are mo-
ments when you feel awkward, and
moments when you feel real and
genuine. But what if you weren’t
these chess pieces? What if you wer-
en’t either the good pieces or the bad
pieces? Is there anything you could
be besides these chess pieces? (This
isn’t a rhetorical question; elicit a re-
sponse from the client.)
If you were a player, you could
try to move these pieces around in an
effort to win, but that doesn’t change
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anything; the player is still caught in


the game and invested in whether the
good or bad thoughts and feelings
win. The games just go on and on.
Sometimes the good pieces win,
sometimes the bad. Can you think of
anything else you might be other
than the pieces or the player? (Again,
elicit a response.)
Here’s an idea: What if you were
the board? That way you could have
the pieces but not be the pieces. The
board is in contact with the pieces.
It’s aware of the pieces and experi-
ences the pieces. But the board itself
never changes, whether there are
more black or white pieces and no
matter where they move. The board
stays the same. It doesn’t care about
the game or who wins or loses. So
from this space, the space of being the
board, can you see how you can hold
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all of your experiences, observing


them and yet not being them?

Visualization can also be very useful for


letting go of self-evaluations and cultivating
the observer self. You can guide the group in
a visualization where they first think of a
time when they behaved as their “worst self”
and did something they truly regret. Have
them recall and observe specific thoughts,
feelings, and behaviors from that incident.
Then guide them to see that the part of
themselves that observes their “worst self” is
distinct and separate from that self. Here’s a
script for this exercise (based on Ciarrochi &
Bailey, 2008):

Close your eyes and take a few mo-


ments to notice your breath and the
sensations in your body.
Now think back to a time when
you were at your worst… Imagine, as
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vividly as you can, being this “worst


self”… Notice the feelings that push
and pull at you. Notice how your
“worst self” thinks. Let yourself be
aware of specific thoughts… See how
your “worst self” behaves with others
and how far this is from your values.
Now notice that, within you,
there’s somebody looking at this
“worst self.” This is a self that
watches your “worst self” and wit-
nesses everything it experiences. This
part of you is the observer self.
Even though your thoughts, feel-
ings, urges, and sensations are con-
tinuously changing, there is still a
consistent you throughout. There is a
you that can watch all of your experi-
ences without being those experiences
or struggling with them. Just become
aware of this person behind your
eyes who watches your “worst self.”
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Can you experience what it feels like


to be the observer?
Now consider this: If you can ob-
serve your “worst self,” then you are
not the same as that “worst self.” If
you can observe the thoughts and
feelings connected to your worst self,
then you aren’t equivalent to those
thoughts and feelings. You are the ob-
server. Remember the chessboard?
You aren’t the pieces on either side,
fighting all those battles. You aren’t
your thoughts, feelings, and sensa-
tions. You are the one who observes,
notices, and holds all of these pieces.
Can you imagine that you are not
your breathing and your body and its
sensations, that you are not your
emotions or your thoughts? Many
parts of you have changed over the
years. You have aged. Your appear-
ance has changed. Your thoughts and
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feelings are constantly changing. But


the observer self has always been
there, never changing. See if you can
sense this deeper “you.” Think of
yourself as being like the sky, being
an unchanging perspective from
which you notice and hold the ever-
changing weather of your aware-
ness. See if you can let go of your at-
tachment to and struggle with diffi-
cult emotions, thoughts, sensations,
and impulses.

Now notice all of the experiences that


have shown up today—particularly
the difficult thoughts and feelings of
your “worst self.” And as you do, no-
tice that you’re here now, watching
all of it. See if you can make space to
be the observer right now. You are
exactly who you should be. Nothing
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needs to be changed. Nothing needs


to be fixed.

6. Assign Homework
Assign the following homework to be
practiced throughout the week:

▪ Ask group members to commit to


following through on the valued in-
tention identified at the beginning
of the session.

▪ Have them notice when evalu-


ations occur, and then practice
cognitive defusion techniques with
these thoughts.
Session 7
Like session 6, session 7 begins by checking
in on how group members did on following
through on their valued intention for the
week and setting a new intention for the
coming week. Sessions 5 and 6 focused
primarily on cognitive defusion techniques,
although these techniques may have been
applied to other internal experiences as well,
including emotions. From this point forward,
there will be more emphasis on emotions
and emotional exposure—facing the pain
that comes up when schemas are triggered.
However, it’s essential to conduct exposure
only with primary pain, which is unavoidable
and must be accepted, and not with second-
ary pain due to maladaptive schema coping
behaviors. Because anger shows up so often
as a schema coping behavior, this session fo-
cuses on anger so that the exposure work in
sessions 8 and 9 can target the primary pain
beneath the anger.
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Procedures

1. Review group members’ experiences


with the homework from session 6
and set a new intention for the com-
ing week (Valued Intentions Work-
sheet; 15 to 20 minutes).

2. Explore willingness via a discussion


of the inevitability of pain and loss in
relationships (10 to 15 minutes).

3. Discuss anger as a coping strategy


and explore the costs of anger (15 to
20 minutes).

4. Provide psychoeducation on anger


(five stages of anger; 10 to 15
minutes).

5. Explore the costs of resentment


(courtroom metaphor; 5 minutes).
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6. Use a mindfulness practice and visu-


alization to explore the moment of
choice and letting go of resentment
(mindfully eating chocolate and visu-
alizing a resented person; 15
minutes).

7. Assign homework (5 minutes).

1. Review Homework
Ask group members to share their experi-
ence in following through on their valued in-
tention. Explore any barriers that came up
and brainstorm strategies to deal with those
barriers, then have them set a new intention
for the following week. For those who didn’t
follow through, it’s best to continue working
on the previously identified intention unless
they have determined that the intention
doesn’t genuinely reflect their values.
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2. Explore Willingness
To help group members develop willing-
ness to face emotional pain, begin by ex-
plaining that emotional pain is unavoidable
in important relationships:

All close relationships come with pain


and loss. Schemas inevitably get
triggered in these relationships. You
may feel hurt, rejected, or misunder-
stood. You may feel attacked, unap-
preciated, or criticized. Opening up
and being vulnerable in relationships
comes at the risk of feeling these
painful emotions. Never having to ex-
perience any of the pain connected to
your schemas means being alone in
the world, without honest, authentic,
and supportive relationships, where-
as having caring, loving, intimate re-
lationships means sometimes having
painful schema-driven thoughts and
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feelings. If you had a choice, which


would you choose? Would you be
willing to experience the pain, includ-
ing disappointment, hurt, abandon-
ment, rejection, and all of those other
difficult feelings if that would bring
you closer to having authentic and
meaningful relationships?

3. Discuss Anger as a Coping Strategy


As mentioned, anger is a common
schema coping behavior; therefore, many
group members may struggle with this way
of reacting. Because you must look beneath
the anger to uncover the hidden, avoided af-
fect, the session now turns to exploring an-
ger and developing alternative responses.
Here’s a script showing how you might ad-
dress this topic:
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One of the ways we cope when our


schemas get activated in relation-
ships is with anger and aggression.
This is the fight-or- flight reaction at
work. When you sense a threat, your
body is wired to either run and es-
cape the situation or fight for surviv-
al. It’s a protective evolutionary
mechanism, and it’s useful when
you’re actually in a life-threatening
situation, but it usually doesn’t work
very well in close relationships. In re-
lationships, running away or fighting
back usually only makes the situation
worse. Plus, it often increases the
likelihood that what you fear will ac-
tually come true. Fighting may make
others fight back; withdrawing may
make them give up on the
relationship.
When the fight-or-flight system is
activated, the heart starts beating
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fast and pumping blood harder to


prepare us for action. Our thoughts,
feelings, sensations, and urges are
also caught up in the fight-or-flight
response. Everything seems urgent,
and we feel highly reactive.
What kinds of thoughts do you
have when you get angry? Typically,
when we’re angry our thoughts are
more judgmental, hostile, suspicious,
and fearful. Our fears are exagger-
ated and our interpretations of other
people’s actions and motives are
skewed. The impulse to act can feel so
urgent that it may be difficult to take
even a brief moment to evaluate the
long-term consequences and costs.
The experience of anger is kind of
like having a tornado in your body
pulling you to use old coping behavi-
ors to escape the terrible internal
storm. Sometimes anger feels like a
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combination of forces, pushing and


pulling in different directions. But
what if there’s another way to deal
with these moments? What if you
could simply notice the pull to engage
in old coping behaviors to try to es-
cape the feelings and still make the
choice to move in the direction of
your values instead? What if you
could just stay with the storm and ob-
serve it like you would a storm in the
sky: just noticing the feelings, sensa-
tions, memories, images, and urges
that come up? You may not be able to
control those feelings, just like we
can’t control the weather. But you
can remember that weather comes
and goes—that the storm will eventu-
ally pass—and that in the meanwhile
you can choose not to react in ways
you’ll regret later.
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Guide the group in a discussion of how


using anger as a coping strategy has im-
pacted their relationships, the people they
care about, and themselves. Here are some
questions you might ask:

▪ Have you used anger to cope with


other, more painful feelings?

▪ What kind of thoughts do you


have when you get angry?

▪ Does buying into these thoughts


bring you closer to or take you
farther away from your values?

▪ When you’ve used anger as a cop-


ing strategy in the past, what have
the consequences been? Are there
benefits? Are there costs?
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▪ When you get angry, are you


moving closer to or farther away
from your values?

▪ Can you be productive when


you’re angry?

▪ Do you make good decisions in


this mode?

4. Provide Psychoeducation on Anger


Provide psychoeducation to help group
members understand anger, observe their
experiences with anger, and identify the mo-
ment of choice, when they have the option of
responding differently. Here’s an outline of
the five stages of anger (Eifert, McKay, &
Forsyth, 2006) and how you might explain
them:

1. Emotions prior to anger:


Anger is usually preceded by a
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feeling like guilt, shame, anxiety,


or a sense of defectiveness or
deprivation. These emotions are
related to schemas, past experi-
ences, and assumptions about how
you’re going to be treated. When
you get angry, which schemas
have been activated? What emo-
tions do you typically feel before
getting angry?

2. Anger trigger thoughts: Anger


is often triggered by certain types
of thoughts, such as judgments
about others, “shoulds,” memories,
blaming thoughts, and suspicious
thoughts. What kinds of thoughts
tend to trigger your anger?

3. Anger feelings: Once anger has


been triggered, many other emo-
tions arise, such as shame, fear,
feeling threatened, and feeling
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helpless, along with physical sen-


sations like trembling hands, rap-
id heartbeat, and rapid breathing.
What feelings and sensations
come up for you when you get
angry?

4. Impulses to act: The feelings as-


sociated with anger create an urge
to act—often by engaging in old,
problematic schema coping beha-
viors and avoidance strategies.
What do you feel an impulse to do
when you get angry?

5. Anger behavior: The final stage


of an anger episode is what you
actually do in that situation. For
many people, this means yelling,
attacking, accusing, blaming, and
so forth, which are all schema cop-
ing behaviors. How have you be-
haved in the past when you got
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angry? What specific schema cop-


ing behaviors have you engaged
in?

Next, engage the group in a discussion of


these five stages and what they can control;
in other words, where they can find the mo-
ment of choice. Ask the following questions
and allow group members to discuss them:

Keeping in mind that we can’t control


other people’s behaviors, what parts
of the anger experience can we actu-
ally control? Can we control our
thoughts when we get angry—actu-
ally stop ourselves from having cer-
tain thoughts? Can we control our
feelings when we get angry? Can we
control the impulses that come up for
us when we get angry? Which of
these five stages of anger can we
control?
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If group members don’t arrive at the cor-


rect answer (we can control our behaviors),
remind them of this before proceeding.

5. Explore the Costs of Resentment


Habitual anger tends to result in resent-
ment, so this may be a significant issue for
group members. Because resentment (like
schemas) is a long-term pattern of thinking
about and relating to others, letting go of it
can be challenging. Much of the remainder of
the session is devoted to helping group mem-
bers with this. Begin by discussing resent-
ment. The metaphor of a courtroom can be
helpful here:

When we feel that another person has


hurt or harmed us and can’t seem to
let go of our anger, it can build into a
long-term pattern of resentment.
With resentment, we end up hurting
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ourselves more than anyone else.


When we become invested in getting
others to feel and understand our
pain or to take responsibility for our
pain, we tend to get stuck. Life be-
comes more about having others feel
bad about our pain and make up for
that pain than about accepting and
healing our pain. This can hold us
back from living the kind of life we
want to live, as our lives become
more about getting revenge and
gathering evidence against the per-
son who has hurt us, rather than
about taking steps toward our
values.
It’s like life turns into a
courtroom, and the main goal is to
prove the other person guilty—to
make sure the person is convicted of
the crime and sentenced appropri-
ately. We may devote ourselves to
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carrying a briefcase of evidence


everywhere we go and continue to
add more and more evidence. Even-
tually the briefcase becomes so heavy
that it bogs us down. Attempts at
punishing others and making them
feel the pain and suffering they’ve
caused us ends up limiting our own
movement and choices. Being so in-
vested in proving that they’ve
wronged us ends up punishing us.
The question is, how can we move
on and let go of our desire for the oth-
er person to get it? How can we leave
the briefcase of evidence at home,
knowing that it’s still there, that the
crime hasn’t been dismissed or dis-
counted, but that it doesn’t have to be
a burden we must carry with us
everywhere we go? We can acknow-
ledge that we’ve been hurt and
wronged and that we still have the
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choice to leave the evidence at home.


This way we can live the life we want
to live, free from the burden of carry-
ing this evidence.

6. Use Mindfulness and Visualization


to Explore the Moment of Choice
The session concludes with a mindful eat-
ing practice to explore feeling urges and res-
isting them, followed by an extended visual-
ization on resisting the impulse to act on an-
ger and, ultimately, replacing resentment
with compassion. Begin by briefly explaining
mindfulness of the anger experience:

As we’ve discussed, when we get


angry, we become reactive and tend
to act impulsively, but those impuls-
ive behaviors have a high cost in our
relationships. So what can we do to
slow things down so that we can see
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what’s going on and make the choice


to behave differently? We can prac-
tice noticing our anger and all of the
different parts of it: thoughts, feel-
ings, and urges. It’s especially im-
portant to be aware of our urges and
notice the moment of choice that we
have right after an urge comes up
and before we act on it. This is the
moment when we can still choose dif-
ferent actions. In some ways, this is a
lot like observing and describing how
something tastes and the urge to
chew or swallow, so let’s do a brief
mindfulness exercise with eating
chocolate to explore how it works.

Give the group members each a small


piece of chocolate and ask them to notice
every aspect of the chocolate. Before they put
it in their mouths, have them notice what it
looks like, how it smells, and its temperature
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and texture. Then have them put the chocol-


ate in their mouths and observe how it feels,
its flavor, and, most importantly, the urge to
chew or swallow the chocolate. Ask them to
let the chocolate melt in their mouths as
slowly as possible while noticing what it feels
like to not act on an urge or impulse. Help
them identify this as the moment of choice,
when they have an urge to do something but
can choose to do something else.
Next, conduct visualization that explores
using a similar approach to anger, having
group members focus on a specific person
whom they tend to get angry with or resent.
Here’s a sample script:

Now we’ll practice a similar exercise


with anger. Close your eyes and visu-
alize a person you sometimes
struggle with—a person you think
has wronged you in some way. Recall
a specific incident with this
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person—maybe an argument or other


difficult interaction. Let’s explore the
anger slowly, just like we did with the
chocolate. Hold the image of the in-
cident in your mind and notice all of
the different aspects of it. Where are
you? Who are you with? What are
you saying? Notice the sounds,
sights, and smells in that situation.
Let yourself feel some of the pain that
this relationship causes you.
Bring your focus to any difficult
or uncomfortable physical sensa-
tions, perhaps in your stomach, chest,
head, or shoulders. Once you’ve iden-
tified a difficult physical sensation,
raise a hand. (Pause and wait for sig-
nals. Stay with this for a good while if
group members are having trouble.)
Now see if you can stop wrestling
with that physical sensation and just
observe it. The point is not to like the
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feeling, but to experience it as what it


is: a sensation in a part of your body.
Keep noticing that sensation. See
whether you can notice exactly where
that sensation is located in your
body—where it begins and ends and
what shape it has. As you do this, see
if you can drop any struggle or sense
of defense with this sensation and
just have it as a sensation… When
you are a bit more open to this sensa-
tion, raise a hand. (Pause and wait for
signals.)
Notice any emotions that are
arising. Maybe you’re feeling hurt,
shame, fear, or guilt.
Now gently turn your attention to
your thoughts in this situation with
this person you have trouble with.
Simply watch as judgments and eval-
uations come up. Just notice and la-
bel them, then let them go. You can
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say to yourself, “There’s a judgment”


or “Thank you, Mind, for that
thought,” but then let it go without
getting involved in it. Just keep noti-
cing judgments, stories, and criti-
cisms and letting go of each.
Now notice your impulses. How
do you feel pulled to react in the diffi-
cult interaction you’re imagining? Do
you want to escape? Do you feel an
urge to attack? Notice the storm
within, pulling you to use old coping
behaviors, and identify the specific
behavior you’re pulled to engage in.
Now, as you’re observing all of
the sensations, emotions, thoughts,
and impulses that your anger brings
up in you, see if you can notice
whether this pain is connected to a
schema. Also see if you can notice
any other emotions underneath the
anger. Maybe you were feeling
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shamed when you became angry.


Maybe you were feeling rejected
when you became angry. Maybe you
were feeling criticized and your de-
fectiveness schema was activated.
When you’ve identified a schema that
has been activated, raise a hand.
(Pause and wait for signals.)
Now turn your attention to this
person who you feel has done you
wrong. Notice his or her behaviors.
Can you try to imagine what schema
might have been activated for that
person? Maybe he or she criticized
you because of feeling rejected. Per-
haps this person feels guilt or shame
and is blaming you for it. Maybe this
person feels unworthy and is trying
to avoid that feeling by attacking
you. See if you can get a sense of
what schema this person might be
trying to avoid.
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Now I’ll ask you to see if you can


find some empathy for this person.
Can you notice how the other per-
son’s behaviors in that situation
brought more pain to him or her?
Notice the other person’s pain. See if
you can begin to feel some acceptance
of this person. This is who the person
is and how he or she is in the world.
Sometimes this person is difficult to
be with because of struggling so
much to avoid his or her own pain. In
this moment, see if you can accept
this person just as he or she is, even
with the behavior that brings you
pain. See if you can extend compas-
sion to this person and let go of your
anger and resentment.

Afterward, take a few minutes to discuss


group members’ experiences during the
visualization.
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7. Assign Homework
Assign the following homework to be
practiced throughout the week:

▪ Have clients commit to following


through on the valued intention
identified at the beginning of the
session.

▪ Encourage them to notice mo-


ments when schemas get activated,
then try to slow things down and
identify related thoughts, feelings,
and urges. Ask group members to
also notice their actual response
and whether they feel better or
worse afterward.
Session 8
Session 8 also begins with checking in on
how group members did on following
through on their valued intention for the
week and setting a new intention for the
coming week. Having explored anger and the
emotions beneath anger in session 7, you can
now turn to exposure to the primary pain as-
sociated with schema activation. From this
point forward, defusion and exposure work
proceed in tandem, as difficult thoughts of-
ten bring up difficult emotions, and vice
versa. To that end, session 8 includes a vari-
ety of visualizations and experiential exer-
cises with a focus on letting go of old control
strategies and not identifying with painful
schema-related affect and cognitions.

Procedures
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1. Review group members’ experiences


with the homework from session 7
and set a new intention for the com-
ing week (Valued Intentions Work-
sheet; 10 to 15 minutes).

2. Practice defusion through an experi-


ential exercise in wearing labels (5
minutes).

3. Provide psychoeducation on emo-


tions and the unworkability of control
strategies (understanding what we
can and cannot control and that we
can’t get rid of internal experiences;
20 to 25 minutes).

4. Explore the costs of avoidance of


painful emotions using an experien-
tial exercise (Exploring the Flip Side;
15 to 20 minutes).

5. Discuss the experience of defusing


by wearing labels (5 minutes).
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6. Explore letting go of old control


strategies using an experiential exer-
cise (Dropping the Rope; 10 to 15
minutes).

7. Conduct a visualization for develop-


ing the observer-self perspective and
defusing from schemas (visualizing
schema-triggering events from vari-
ous stages of life; 5 to 10 minutes).

8. Assign homework (5 minutes).

1. Review Homework
Ask group members to share their experi-
ence in following through on their valued in-
tention. Explore any barriers that came up
and brainstorm strategies to deal with those
barriers, then have them set a new intention
for the following week. For those who didn’t
follow through, it’s best to continue working
on the previously identified intention unless
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they have determined that the intention


doesn’t genuinely reflect their values.

2. Practice Defusion by Wearing


Labels
Have group members select a particularly
painful schema-related self-evaluation. You
might bring up the sales representative and
ask them to choose a self-evaluation that’s an
especially pushy sales rep. Have them write
the evaluation on an index card and then
tape it to themselves and wear it as the ses-
sion proceeds. Write and wear a self-evalu-
ation yourself so you can model the process
and share some of the embarrassment.

3. Provide Psychoeducation on Emo-


tions and Control Strategies
To help group members develop more
willingness to have difficult emotions, spend
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some time discussing emotions and the


problems with control strategies. A meta-
phor of a hungry lion (based on Hayes &
Smith, 2005) can be useful in explaining the
problems with efforts to control internal ex-
perience. Here’s a script showing how you
might cover these topics:

We’ve been talking about emotions


that come up for us related to our
schemas, such as shame, hurt, and
anger. We’ve been exploring how
we’ve been relating to this pain. In
the last session when we were talking
about anger, we explored whether we
can really control the pain or get rid
of it and worked on learning to
simply observe our pain, watching it
with acceptance and without trying
to change it. Just to be clear, this
doesn’t mean condoning the pain or
liking it; it just means acknowledging
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the pain without trying to push it


away. This is a place where we can
stop and observe our experiences and
urges without acting on them.
The Serenity Prayer, which is
used in 12-step programs, can be
helpful here. It says, “God, grant me
the serenity to accept the things I
cannot change, courage to change the
things I can, and wisdom to know the
difference.” The most difficult part of
this is distinguishing between the
things we can and cannot control.
For the most part, the things that we
can control are our behavior, our ac-
tions, and what we want our life to
stand for—our values and the choices
we make. As far as the things that we
cannot control, the list is long, but
some of the key things are thoughts,
memories, bodily sensations, urges,
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impulses, and feeling—and the beha-


vior of others.
If you don’t like this chair, what
can you do? You could pick it up, just
like this, put it outside, and get rid of
it. You could throw it out and per-
manently get rid of it. But what
about your thoughts, feelings, and
memories? Can you do that with
them? Why can’t you throw thoughts
out? Why can’t you permanently get
rid of them? Thoughts and feelings
aren’t tangible objects. They can’t be
held, touched, or permanently
moved. Controlling internal experi-
ences simply doesn’t work in the
same way as controlling objects in
the outside world.
However, our culture gives us a
lot of messages that we can control
our internal experiences in the same
way as we can control objects in our
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environment. We hear these kinds of


messages all the time: “Calm down,”
“Don’t worry,” “Pull yourself togeth-
er,” “Chill out,” “Where there’s a will
there’s a way,” and so on. As a child,
you learned not to touch a hot
stove—to avoid it—and that’s a good
thing. But internal pain cannot be
avoided. Yet we often try to respond
to emotional pain and other difficult
internal experiences as if they are a
hot stove—as if thoughts, feelings, im-
pulses, and sensations can actually
harm us, and as if we can avoid
them.
We cannot arbitrarily choose to
have more or less of any emotion
connected to our schemas. Since fear
is an emotion that comes up with
most schemas, let’s use it as an ex-
ample. Here’s a little thought experi-
ment that helps demonstrate the
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problem with trying to control emo-


tions. Suppose I tell you that in a mo-
ment a lion will enter the room and
that this lion preys only on people
who show fear or attempt to run
away. This lion is incredibly sensitive
and will be able to detect the slightest
trace of fear that comes up for you.
As long as you don’t feel afraid or try
to run away, you’ll be completely safe
and the lion won’t eat you. But if you
experience even a trace of fear or try
to run, the lion will notice this and
eat you.
What would happen? You’d prob-
ably start feeling terrified. Can you
control that fear? Can you make
yourself not feel afraid? How about
running? Do you think you could con-
trol whether you’d run? Can you
make yourself not run? You’d prob-
ably be able to stop yourself from
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running, but could you stop yourself


from feeling afraid in the same way?
Now think about what would hap-
pen if I told you that as long as you
pet the lion, it won’t eat you. What
would you do? You’d probably start
petting it, right? What if I told you
that as long as you feed the lion, it
won’t eat you? What would you do?
You’d probably offer it some food.
The point here is that controlling our
behaviors and what we do with our
hands and feet is very different from
trying to control our emotional re-
sponses. Thoughts, feelings, and sen-
sations aren’t like objects in the
world. We can’t move them around
and control them.
Changing and controlling our be-
haviors is very different from at-
tempting to change our internal ex-
periences. We simply cannot relate to
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our internal experiences the way we


do to objects in the world. It just
doesn’t work. Our thoughts, sensa-
tions, emotions, impulses, and
memories are in us, and we can’t run
away or escape from ourselves.
Pain and suffering happen to 100
percent of people. At one point or an-
other, everyone feels disappointed,
criticized, lonely, or sad. Have you
ever managed to permanently re-
move an emotion? Have you been
able to get a certain thought to never
show up in your brain again? It al-
most seems like the more you don’t
want those experiences, the more you
have them. The more you don’t want
to be angry, the angrier you get. The
more you don’t want to be depressed,
the more depressed you become. If
you’re prone to anxiety, you might
start getting anxious about your
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anxiety. You might start wondering,


“Why am I anxious? Should I be this
anxious? Where did this anxiety
start? Are other people as anxious as
I am?” All of that just builds more
anxiety. In the end, struggling with
difficult emotions actually causes
more pain.

4. Explore the Costs of Avoiding Pain-


ful Emotions
To help the group understand the costs of
avoidance, conduct an exercise similar to Ex-
ploring the Flip Side, in chapter 7. Ask for a
volunteer from the group to come up and do
an exercise related to the thought that he or
she wrote on the index card that he or she is
wearing.
Ask the volunteer which schema this
thought might be connected to and continue
to write down more thoughts and feelings
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that are connected to this schema on the vo-


lunteer’s index card. After you’ve written
down five or six thoughts and feelings on the
card, put the card in front of the volunteer,
really close to the person’s face. Almost taunt
the volunteer with the card in an effort to get
him or her to look away from it or physically
push it away. You can even read the card out
loud, playing the role of the volunteer’s mind
while holding the card up in front of him or
her. Ask, “How do you usually relate to these
thoughts and feelings when they come up for
you?”
Show the volunteer how he or she gets
caught in the struggle of not having certain
thoughts and feelings and tries to push them
away, avoid them, or look away from them.
Have the volunteer notice the struggle in-
volved in attempting to avoid these thoughts
and feelings. Explore how these thoughts
and feelings may be functioning as barriers:
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Let’s look at the thought or feeling on


this card. Has this thought or feeling
ever stopped you from doing
something that was important to
you? What specific thing has this
thought kept you from doing?

On the back of the index card write down


the valued intention for which this thought
or feeling has been a barrier. Identify the re-
lated value and write that as well, and have
all of the group members do the same. Then
bring the front of the index card, with its
schema-driven thought or feeling, closer to
the volunteer and help the volunteer see that
the farther away he or she pushes the pain,
the farther away the value is:

What could you do with this card if


you wanted to continue escaping and
running from this experience—if you
wanted to get rid of this thought or
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feeling? You can continue to try to


push it away or even throw it away.
(Move the card farther away from the
client, crumple it up, or put it in the
garbage.)
But have you ever managed to
permanently remove this thought or
feeling? Have you managed to keep it
far away from you? And if you do
toss this card away, even if it does get
it farther away from you, what else is
farther away? What else is on that
card? The farther away that thought
or feeling is, the farther away your
value is. The closer the thought or
feeling is, the closer the value is. Can
you get closer to this value without
getting closer to this pain? So the
question is, would you be willing to
have the thought or feeling on this
card if it means that you’ll also be
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closer to the value that’s on the other


side?

Having suggested that the only way to be


closer to the value is through willingness to
be closer to schema-related pain, help the
group see how they might make space for
difficult thoughts and feelings. Take the vo-
lunteer’s index card and place it on his or her
lap. Ask what this feels like, then explore de-
fusion from difficult thoughts and feelings
using questions such as these:

How many words are there on the


front of your card? How many letters
are there? What color ink are they
written in? Can you read them back-
ward? Can you have these letters and
words and just observe them? Can
you have them just as they are,
without pushing them away or
struggling?
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Ask group members to carry the index


card with them for the following week as an
exercise in having painful thoughts and feel-
ings without buying into them:

Now I’m wondering if you would be


willing to take this card with you and
keep it in your pocket for the next
week. Look at the thought or feeling
on the front once a day. Don’t argue
with it. Don’t avoid it. Don’t buy into
it. Just look at it, stay in contact with
it, and put it back in your pocket.
Would you be willing to do that? And
how about a further step? Would you
be willing to commit to doing the ac-
tion on the back of that card, bring-
ing the card with you as you take
that step?

5. Discuss the Experience of Defusing


by Wearing Labels
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Ask clients what it felt like to wear the la-


bels with painful self-evaluations. Ask
whether their feelings or discomfort about
the labels changed over the course of the ses-
sion or stayed the same. Did they forget they
were wearing these labels, or did they feel
self-conscious about it throughout the
session?

6. Explore Letting Go of Control


Strategies
The experiential exercise Dropping the
Rope, discussed at length in chapter 7, can
help group members understand the limita-
tions of control strategies. It also helps
demonstrate the benefits of behavioral flex-
ibility in the face of perceived barriers. In a
group setting, ask for a volunteer to do the
exercise. You’ll need a somewhat short piece
of rope—about six feet long—for this exer-
cise. Here are the specific steps:
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1. Ask about a recent schema-trigger-


ing situation and have the volun-
teer describe the associated feel-
ings and thoughts, then objectify
this schema-related pain by asking
questions about its shape, size, col-
or, weight, texture, and so on. You
can also ask whether any of these
physical qualities are changing or
whether the pain is moving in any
way.

2. When the volunteer has clearly de-


scribed the schema-related pain as
an object, explain that you’re tak-
ing the object out of him or her and
putting it in you. Act out this pro-
cess of transferring the pain.

3. Hold one end of a rope and ask the


volunteer to hold the other end.
Then inquire about how the
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volunteer has been relating to this


pain when it shows up.

4. Pull on the rope and let the volun-


teer struggle with you as the
schema-related pain. Remind the
volunteer of the feelings and
thoughts. Pull the volunteer
around or let him or her try to get
away by pulling you for a minute or
two.

5. Encourage the volunteer to explore


alternative solutions. If the volun-
teer doesn’t come up with the idea
of dropping the rope, solicit addi-
tional solutions from the group. If
necessary, you can eventually sug-
gest dropping the rope.

6. After the volunteer drops the rope,


continue to represent the pain and
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follow the volunteer around


wherever he or she goes.

7. Help the volunteer notice that even


after he or she drops the rope, the
schema-related pain is still there.
However, the volunteer is now free
to move around, including toward
important values. Even though the
pain is still there, the volunteer is
setting the direction rather than
being constrained and locked in a
struggle.

7. Conduct a Visualization for Devel-


oping the Observer Self
Another way to help group members de-
velop the observer-self perspective and disid-
entify with their self-evaluations and other
schema-driven thoughts and feelings is with
a visualization that explores a recent
schema-triggering event and how it relates to
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similar situations earlier in life. Then the


visualization shifts to a recent positive exper-
ience to help underscore how thoughts, feel-
ings, and other private experiences are al-
ways changing and therefore do not and can-
not define us. Here’s an outline for the visu-
alization (based on Hayes et al., 1999):

1. Have group members sit comfort-


ably and close their eyes.

2. Ask them to remember a moment


during the past week when a
schema was triggered. Guide them
in vividly recalling the incident and
all of the associated images,
sounds, physical sensations, emo-
tions, and thoughts. Direct them to
particularly notice thoughts, stor-
ies, judgments, and predictions
and whether these thoughts seem
familiar—like old, often-repeated
stories.
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3. Have them notice that the self ob-


serving the memory is the same as
the self in the memory.

4. Have group members let go of the


recent memory and ask them to try
to recall one of the first times when
the schema from that memory was
triggered and that familiar story
began to arise—an early experience
perhaps with a parent or caregiver,
at school, or with friends. Guide
them in vividly recalling the event
and all of the associated images,
sounds, physical sensations, emo-
tions, and thoughts. Ask whether
the stories connected to this early
event seem to manifest in current
relationships, or whether they find
themselves trying to escape or
avoid this experience of them-
selves. Ask them to compassion-
ately make space for this difficult
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memory and their younger self and


guide them in accepting all of these
experiences, perhaps using the
metaphor of the sky and the
weather.

5. Have them notice that the self ob-


serving this childhood memory is
the same as the self in the memory.

6. Have group members let go of that


early memory and recall a recent
situation where they experienced
thoughts and feelings opposite
those triggered by the
schema—perhaps a situation where
they felt confident, secure, or lov-
ing toward themselves. Again, have
them bring to mind all of the de-
tails of the situation: where they
were, who they were with, and
what was said, along with the asso-
ciated images, sounds, physical
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sensations, emotions, and


thoughts.

7. Finally, have them notice that the


self observing this memory is the
same as the self in the
memory—and in all of the memor-
ies brought to mind in this visual-
ization, both positive and negative.

8. Assign Homework
Assign the following homework to be
practiced throughout the week:

▪ Ask group members to commit to


following through on the valued in-
tention identified at the beginning
of the session, as well as the inten-
tion on the index card to be carried
over the course of the week.
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▪ Have them notice whether they can


make space for any uncomfortable
feelings that come up while acting
on values.
Session 9
Again, the session begins with checking in on
how group members did on following
through on their valued intention for the
week and setting a new intention for the
coming week. Because this is the next-to-last
session, it reviews many of the topics and
skills from previous sessions and gives group
members an opportunity to practice and
commit to new behaviors. An important fo-
cus of this session is teaching group mem-
bers effective communication skills. This ses-
sion isn’t as full as sessions 1 through 8, cre-
ating some flex time to cover material that
didn’t fit in earlier sessions. You can also use
the extra time to address any lingering issues
group members may be experiencing.

Procedures
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1. Review group members’ experiences


with the homework from session 8
and set a new intention for the com-
ing week (Valued Intentions Work-
sheet; 10 to 15 minutes).

2. Conduct a visualization exploring re-


actions to recent schema-triggering
events (5 to 10 minutes).

3. Discuss effective communication (A


Formula for Effective Communication
handout; 5 to 10 minutes).

4. Conduct a role-playing exercise to


practice defusion and alternative re-
sponses to the event visualized earli-
er in the session (Defusion Skills
handout; 45 minutes).

5. Conduct a visualization bringing


mindfulness and compassion to
schema-related pain, again exploring
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the event visualized earlier in the


session (5 minutes).

6. Assign homework (5 minutes).

1. Review Homework
Ask group members to share their experi-
ence in following through on their valued in-
tention. Explore any barriers that came up
and brainstorm strategies to deal with those
barriers, then have them set a new intention
for the following week. For those who didn’t
follow through, it’s best to continue working
on the previously identified intention unless
they have determined that the intention
doesn’t genuinely reflect their values.

2. Conduct a Visualization Exploring a


Recent Schema-Triggering Event
Ask the group to close their eyes and
visualize a recent event in which their
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schemas were triggered in an important rela-


tionship and they didn’t respond in a way
that aligned with their values. As always with
visualization, provide guidance on attending
to visual, auditory, kinesthetic, and other
sensory aspects of the experience. Ask them
to see where they were, hear what was said,
and notice what they felt physically—both at
the time and in the moment, during the visu-
alization. Have them observe thoughts and
feelings as well, then help them turn their at-
tention to urges, impulses, and their actual
behavior. In the process, you can revisit the
moment of choice, underscoring that it isn’t
necessary to act on behavioral urges, and
guide the group toward assessing the costs of
continuing to resort to old coping behaviors:

How are you pulled to behave? What


do you want to say or do? Notice that
you don’t have to act on any impulse.
You can watch the urge to engage in
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old coping behaviors while still keep-


ing your commitment not to do so.
How did you actually behave? What
did you say and do? What was the
impact on the other person? Did it
make your relationship closer, or did
it create more distance? Slow
everything down and just watch the
scene unfold in slow motion.

Afterward, explore what this experience


was like for the group. Have group members
envision a values-based response to the situ-
ation. What would they have liked to do dif-
ferently? How could they have behaved in a
way that would enhance the relationship?

3. Discuss Effective Communication


An optional module of the group protocol
(absent from the individual protocol) is as-
sertiveness training. It is included here
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because clients treated in a group setting of-


ten display poor interpersonal skills. When
schemas are triggered, these clients fre-
quently lack the ability to communicate their
needs and feelings effectively.
If covering effective communication in
group therapy, give group members the
handout A Formula for Effective
Communication.

A Formula for Effect-


ive Communication

Here’s a straightforward formula for com-


municating effectively and making assert-
ive requests. Simply fill in the blanks as
appropriate to your situation:
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1. When [describe the specific event


objectively and nonjudgmentally],

2. I felt [describe how you felt].

3. I need [describe your need in terms


of values] (for example, “I need con-
nection, [respect, honesty, and so
on]”).

4. Would you be willing to [specific re-


quest describing how this person can
meet your need]?

Here’s an example:

1. When we had plans to meet at two in


the afternoon on Saturday and you
showed up a half hour late,

2. I felt hurt and concerned.

3. I need to be able to count on you


and trust you.
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4. Would you be willing to be more


prompt in the future and make sure
that you follow through with our
plans?

4. Conduct a Role-Playing Exercise to


Explore Alternative Responses
Ask a volunteer to come up to the front of
the room to role-play the situation from his
or her visualization and practice responding
differently. Ask for details about the event so
you can role-play the other person in the
situation. Provide the volunteer with a copy
of the Defusion Skills handout. Ask the vo-
lunteer to use mindfulness and defusion
skills—and effective communication skills as
needed—to respond in a way more aligned
with his or her values and in a way that will
enhance the relationship.
Afterward, engage the group in a discus-
sion about the role play and ask group
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members to share the values-based behavi-


ors they wish they had used in their visual-
ized situations. Ask them to set an additional
intention, beyond those committed to at the
beginning of the session, to act on a specific
value in an important relationship. Have
them write this intention down.

5. Conduct a Visualization Bringing


Mindfulness and Compassion to
Schema-Related Pain
To conclude the session, conduct a visual-
ization bringing mindful attention to the
schema-related pain associated with the
event visualized throughout this session. The
goal of the visualization is to help group
members open to acceptance and willingness
with painful emotions and to help them ex-
tend compassion to themselves. Here’s a
script you might use:
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Get comfortable in your chair and


gently close your eyes. Begin by fo-
cusing your attention on your
breathing for a few breaths.
Now recall that moment when
your schema was triggered in an im-
portant relationship—the event
you’ve been visualizing throughout
this session. Maybe you felt deprived,
abandoned, defective, or ashamed.
Try to contact the core feeling in that
moment when the schema was
triggered. Where in your body do you
experience that schema feeling?
Look back and try to recall how
many times that feeling came up for
you today. How many times over the
past week? How many times over the
past month? Try to see if you can re-
call the very first time you had this
feeling or one of the first times you
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had it. When you have that earliest


memory in mind, raise a hand.
Has this feeling been with you for
a long time? Does it come up in many
different relationships? How have
you related to this feeling? Stay with
this pain and breathe with it. If you
notice any urges to escape or push
away this experience, just notice that
urge and see if you can allow yourself
to stay with this experience. What
does it feel like to fully experience this
feeling without struggling? Can you
allow yourself to feel 100 percent of
your experiences with compassion
and gentle kindness toward yourself?
Can you make space for all the parts
of your experience? Does this experi-
ence have to be pushed away or
avoided? Or is this pain something
you can handle—something you can
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observe nonjudgmentally and fully


experience?
Notice any thoughts, emotions,
sensations, and urges that are com-
ing up or getting more intense and
just observe them all with kindness
and willingness, as if this schema-re-
lated pain is a crying baby. See if you
can allow yourself to invite this pain
in and embrace it as a part of you, a
part that’s always been there with
you and always will be there. Noth-
ing needs to be fixed; nothing has to
be changed. You are exactly where
you should be. When you are ready,
gradually widen your attention and
slowly open your eyes.

6. Assign Homework

▪ Have clients commit to following


through on the valued intention
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identified at the beginning of the


session, as well as the new inten-
tion in an important relationship,
established after the role play on
alternative responses.

▪ Ask group members to practice


willingness to feel schema-related
feelings while not acting on the re-
lated behavioral impulses.

▪ Encourage them to look for oppor-


tunities to practice alternative,
values-based responses to schema-
triggering situations.
Session 10
As with session 9, this final session isn’t as
full as the first eight, creating some flex time
to cover material that didn’t fit in earlier ses-
sions and to address any lingering issues
group members may be experiencing. This
concluding session begins with an expansive
mindfulness exercise that continues the work
of fostering self-compassion and compassion
toward others as an avenue toward healing.
Time is devoted to exploring members’ ex-
periences in the group, and then group mem-
bers are given a final opportunity to practice
alternative responses. The main priority of
this session is giving group members the op-
portunity to come up and practice new
values-based behaviors and get feedback
from the group. The session concludes with
an exploration of potential barriers and plan-
ning strategies that will allow group mem-
bers to follow through with committed ac-
tions in spite of these barriers.
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Procedures

1. Conduct a mindfulness meditation


promoting self-compassion and com-
passion toward others (5 minutes).

2. Review group members’ experiences


with the homework from session 9
(10 minutes).

3. Discuss group members’ experiences


over the past ten weeks (10 to 15
minutes).

4. Conduct a role-playing exercise to


practice defusion and alternative re-
sponses to specific schema-trigger-
ing events (Defusion Skills handout
and A Formula for Effective Commu-
nication handout; 35 minutes).
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5. Discuss potential barriers and devel-


op strategies for acting on valued in-
tentions in spite of barriers (15
minutes).

6. Have group members commit to a


new intention (10 minutes).

7. Administer post-treatment
assessments.

1. Conduct a Mindfulness Meditation


Focused on Compassion
Helping group members build compas-
sion for themselves and others will increase
their willingness to be present with their own
pain and the pain of others. This acceptance
of schema-related pain is a necessary step in
taking action in valued directions. Here’s a
script for a visualization to build compassion
(Eifert and Forsyth, 2005):
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Start by closing your eyes and turn-


ing your attention to the natural
rhythm of your breath. You need not
control your breath in any way. Just
tune in to your body and your breath.
Now bring to mind a moment
when a schema was triggered in a re-
lationship. Get in touch with the pain
and hurt that this schema brings up
in you. Then, with your next inhala-
tion, breathe in all of the negativity
and pain. Breathe in that discomfort
with the realization that what you
are feeling at this very moment is be-
ing felt by millions of people all over
the world. You are not alone with
this. Everyone has schemas. Every-
one feels hurt, rejection, shame, and
fear in relationships. This pain is part
of being a human being in this world.
Someone in the world is probably
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experiencing this same pain, right


now, this very moment.
Allow yourself to breathe in this
pain more deeply. With each breath,
breathe in your pain, as well as the
pain and suffering of others who are
experiencing pain. Make space in
your body for all of the pain that
comes with the experience of being
human.
Now, with each exhalation,
breathe out relief, compassion, and
kindness to others who are suffering.
Continue opening up the space inside
you to breathe in more of this
pain—your own and that of oth-
ers—and each time you exhale,
breathe out relief, tenderness, and
compassion. Find the natural rhythm
of your breathing. Then, each time
you inhale, open yourself up and be
more willing to make space for all
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your experience. You don’t have to


push away and escape the hurt and
pain that shows up for all human be-
ings. We were made to handle and
contain all of these experiences.
Now, whenever you’re ready,
gradually open your eyes with the in-
tention to continue practicing kind-
ness and compassion toward the pain
of humanity.

2. Review Homework
Ask group members to share their experi-
ence in following through on their valued in-
tention and discuss any barriers that came
up. (Later in the session, you’ll conduct a
thorough discussion of potential future bar-
riers and strategies to deal with them and
also ask members to commit to a new
intention.)
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3. Discuss Members’ Experiences in


the Group
Engage in a group discussion regarding
group members’ experiences with the group
in general and with exploring and acting on
their values. Explore which strategies
worked for them and which didn’t work so
well. Ask what they feel they’ve gained and
what was difficult for them. Ask them to
share anything that they learned about
themselves or their behaviors in relation-
ships. Also ask what they feel they still need
to work on and what values they’re going to
continue to act on. Encourage group mem-
bers to continue to identify valued intentions
and follow through with them on a weekly
basis.

4. Conduct a Role-Playing Exercise to


Explore Alternative Responses
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Reprise the role-playing exercise from


session 9, asking for volunteers and using
schema-triggering events that occurred over
the past week. With each volunteer, begin by
asking the person to role-play his or her old,
maladaptive coping behavior, then have oth-
er group members give feedback and offer
suggestions regarding new, values-based be-
haviors. Next, do the same role play again,
but this time with the volunteer practicing a
values-based response characterized by hon-
est and effective communication and vulner-
ability. (If necessary, give group members
the handouts Defusion Skills and A Formula
for Effective Communication.) Ask each vo-
lunteer in turn to explore the old and new
behaviors and what it felt like to behave
differently.

5. Discuss Potential Barriers and


Strategies for Working with Them
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To conclude the session, explore diffi-


culties with willingness and committed ac-
tion. Ask group members to identify current
barriers to valued intentions. Spend some
time discussing strategies for following
through on valued intentions despite these
barriers. Then devote some time to exploring
possible future barriers and having group
members suggest strategies for those. Have
group members predict future situations
where their schemas might get triggered and
what new coping strategies they will use to
ensure they seize the moment of choice and
respond based on their values, rather than
reacting based on old, maladaptive schemas.

6. Have Group Members Commit to a


New Intention
Finally, have group members come up
with a commitment to values-based behavior
in a frequently encountered triggering
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situation. Then have each group member


stand up and share that commitment.

7. Administer Post-Treatment
Assessments
If you chose to administer any pre-treat-
ment assessments for use as outcome meas-
ures, have group members complete those
questionnaires again at the end of the
session.
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Publications.
Matthew McKay, PhD, is professor at the
Wright Institute in Berkeley, CA. In private
practice, he specializes in the treatment of
anxiety, interpersonal problems, and depres-
sion. He is coauthor of The Relaxation and
Stress Reduction Workbook, Thoughts and
Feelings, Self-Esteem, Your Life on Purpose,
and many other titles. Combined, his books
have sold more than three million copies.
Avigail Lev, PsyD, is clinical supervisor at
the Berkeley Cognitive and Behavioral Ther-
apies Clinic. She specializes in couples ther-
apy and treating mood disorders and inter-
personal problems.
Michelle Skeen, PsyD, studied schema
therapy under Jeffrey Young. She completed
her postdoctoral work at the University of
California, San Francisco, and maintains a
private practice in San Francisco, CA, where
she lives and works. She hosts a radio show
and is author of The Critical Partner.
www.michelleskeen.com
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Foreword writer Steven C. Hayes, PhD, is


University of Nevada Foundation Professor
of Psychology at the University of Nevada,
Reno. He is author of hundreds of scientific
articles and many books, including Accept-
ance and Commitment Therapy, Relational
Frame Theory, and Get Out of Your Mind
and Into Your Life.
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