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Mindfulness- andAcceptance-Based Behavioral
Therapiesin Practice
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T! "#$L%OR&
PR!SS 'e( )or*London
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O N E
An Acceptance-Based Behavioral
+onceptualization of +linicalProblems
Ma,a a collee student came to therap, because she (as e/periencin
intense an/iet, that (as ma*in it difficult for her to et her school
assinments done and ta*e e/ams. She reported (orr,in that she
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&efinin this underl,in model is critical because the model serves as the
foundation for an individualized formulation of a particular client4sdifficulties. The model also
67
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provides a startin point from (hich (e choose specific assessment
strateies and clini- cal methods and a touchstone to (hich (e return
repeatedl, to evaluate the course and proress of therap,.
The model contains three main elements each of (hich relates to the
others. %irst clinical problems are seen as stemmin from the (a, that
clients :and humans in en- eral; often relate to their internal experiences.
This relationship can be characterized as 0fused1 :a,es Strosahl < 2ilson
6===; entanled :"ermer >??@; or 0hoo*ed1 :+hodron >??7; and is
distinuished b, an overidentification (ith one4s thouhts feel- ins
imaes and sensations. $n other (ords ever,one feels sad from time to
time but a client (ho is fused (ith her internal e/perience ma, define
herself b, that sadness5 for e/ample Ma,a defines herself as 0(ea*1 due
to her an/iet,. This overidentifica- tion or fusion (ith internal e/periences
can set off a cascade of problematic responses. An/iet, is no loner
vie(ed as a natural emotion that ebbs and flo(s5 instead it is seen as a
definin or all-encompassin state (hich can lead to it bein uded and
vie(ed as intolerable and unacceptable. The second element of the model is
experiential avoidance or emotional conitive and behavioral efforts to
avoid or escape distress- in thouhts feelins memories and sensations
:a,es 2ilson "ifford %ollette < Strosahl 6==;. +lients enae in
e/periential avoidance hopin to improve their lives but it often
parado/icall, leads to further distress or diminished 3ualit, of life :e..
a,es et al. 6==;. !/periential avoidance is closel, tied to the (a,s clients
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+onceptualization of +linical 6
elements of these approaches as (ell as traditional conitive-behavioral
approaches to hihliht (hat (e consider the central elements of an
acceptance-based behavioral conceptualization :>; briefl, revie( some of
the research that supports this model and :E; illustrate ho(
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this model can be applied to specific clinical problems. 2e conclude (ith
an overvie( of ho( this model translates into intervention and continue in
the ne/t t(o chapters (ith discussion of ho( this model uides individual
treatment plannin assessment and deliver,.
Our approach to understandin problematic clinical behaviors is based
in a behav- ioral conceptualization. That is (e understand responses to be
learned throuh both associations and conse3uences and (e (or* to
identif, the function of problematic responses to determine strateies for
intervention. 2e see human difficulties as arisin from a combination of
bioloical predispositions environmental factors and learned habits that
lead to a host of reactions and behaviors that occur automaticall, (ithout
a(areness or apparent choice. Learnin happens in several (a,s. 2e can
learn throuh direct experience. %or instance a (oman (ho (as raped
miht learn an association bet(een the smell of specific colone and
daner (hich motivates her to avoid others (ith that same scent. 2e also
learn throuh conse3uences that consistentl, follo( partic- ular behaviors
either reinforcin or punishin them and thus alterin their fre3uenc, as
(hen an individual continues to drin* e/cessivel, because of the stress-
relievin properties of alcohol. Learnin also occurs throuh modeling and
observation such as seein the reactions and behaviors of our parents or
siblins and throuh instruction such as bein told to act in certain (a,s or
not to sho( certain emotions. These learned patterns of behaviors often
serve a useful function particularl, in the short term5 ho(- ever as conte/ts
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+onceptualization of +linical >
impulsivel, and automaticall, enain in actions that are not valued due
to their e/perientiall, avoidant function; is thouht to contribute to distress
and diminish 3ualit, of life.
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RESTRICTED, ENTANGLED, FUSED INTERNAL
AWARENESS Limits in Internal AwarenessMan, clinical theories hihliht the potential role of deficits in internal or
e/periential a(areness in ps,choloical difficulties and the role of
increased a(areness in promot- in ps,choloical (ell-bein.6 +onsistent
(ith these models from an acceptance-based behavioral perspective
deficits in a(areness ma, manifest in several (a,s that indicate clinical
problems :these different (a,s ma, co-occur in the same individual;. %irst
cli- ents are often unaware of their internal e/periences not reconizin
emotional coni- tive or ph,sioloical responses that precede problematic
behaviors :e.. ale/ith,mia;. +lients ma, also misunderstand their internal
responses labelin ph,sioloical sensa- tions as huner (hen the, in fact
reflect distress or mista*in one threatenin emotion :such as an/iet,; for
another more personall, acceptable one :such as aner;. &imin- ished or
inaccurate a(areness reduces clients4 abilit, to use their emotional
responses functionall, and ma, lead them to react in (a,s that are puzzlin
to them. %or instance a chronicall, lonel, client ma, tell ,ou that he does
not attend social events because he does not eno, them (hen in fact he
is avoidin them due to his unreconized an/iet, and (ould ver, much li*e
to be more sociall, enaed. Another client ma, surprise herself b,
respondin aressivel, to a co(or*er because she did not realize she had
felt resentment and aner due to her co(or*er 4s repeated apparent
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+onceptualization of +linical >6 &arren olo(*a in his dissertation suests that e/periential a(areness ma, be a common
factor across diverse forms of ps,chotherap, :olo(*a >??85 olo(*a < Roemer >??7;.
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neative mood state5 ho(ever this a(areness differs sinificantl, from thea(areness that ps,chotherap, aims to cultivate. %irst this a(areness ma,
not be clear in that indi- viduals ma, perceive the, are enerall, distressedbut not be able to pinpoint specific and subtle shifts in their emotionalph,sioloical or conitive state. %or instance a client miht describe apanic attac* that lasted > (ee*s :(hich is not ph,sioloicall, possible; orfeelin 0bad1 (ithout a clear sense of (hether he feels sadness anerfear or a blended emotion. $ndividuals4 a(areness ma, be critical
!udgmental or reactive. %or instance a client (ith recurrent depressiveepisodes miht notice her sadness and be ver, distressed that she is sad
aain thin* her sadness is a sin that a debilitatin depression is returninand feel alarmed b, its occurrence. These reactions li*el, per- petuate and(orsen the sadness possibl, leadin to depression rather than promotinadaptive functionin. Ma,a provides an e/ample of this *ind of 3ualit, ofa(areness. She (as ver, a(are of an, sins of an/iet, and responded tothem (ith self-udment and criticism further perpetuatin her an/iet,.A(areness can also become narrowed or selective. %or instance individuals(ith an/iet, disorders ma, be so a(are of a potential threat that the, donot notice other cues in their environment that sinal safet, or the, ma, be
so focused on their an/ious respondin that the, do not detect theoccurrence of positive emotional responses. This selective attention toan/iet, further e/acerbates their sense that their an/iet, is unchanin andpervasive.
All of these e/amples of (a,s in (hich the 3ualit, of e/perientiala(areness can be problematic can be thouht of as aspects of a larercateor, of overidenti"ication or 0"usion1 :a,es Strosahl < 2ilson 6===;or 0entanglement1 :"ermer >??@; (ith one4s internal e/perience in a (a,
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+onceptualization of +linical >>Althouh the terms "ear o" "ear and "ear o" emotion have been used in the literature these
concepts are more accuratel, labeled 0an/iet, of1 or 0distress about1 fear and other emotions
in that the, describe an anticipa- tor, or reactive process (ith a loner duration than fear
:Barlo( personal communication5 see Barlo( 6==6 for a discussion of the role of
an/iet,Dd,sth,mia in response to the e/perience of basic emotions in emotional disorders;.
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Barlo( 6==65 Bor*ovec < Sharples >??C;.E 2hile a (hole rane of
internal responses ma, naturall, come and o for all of us humans have
also developed an abilit, to respond to these e/periences in certain (a,s
that ma, lead them to become more riid 0stic*,1 or infle/ible resultin in
clinical problems. %or instance models of panic note that panic attac*s are
common across the population but onl, some people develop panic
disorder and these seem to be the individuals (ho e/perience an/ious
apprehen- sion about future panic attac*s :Barlo( 6==6;. Relatedl,
behavioral models suest that individuals (ith panic disorder have
learned to e/perience an/iet, in response to their bodil, sensations:interoceptive conditionin5 Barlo( >??>;. This distress or apprehension
seems to be the crucial element of panic disorder and successful treat-
ments taret it directl,5 successfull, treated individuals continue to
e/perience panic sensations but no loner e/perience heihtened an/iet, in
response to these sensations. The reactive a(areness of bodil, sensations
that characterizes individuals (ith panic disorder is also narro(ed so that
the, focus solel, on arousal sensations and ma, have limited emotionala(areness. %or instance a recent stud, found that individuals (ho reported
a hih level of panic s,mptoms reported more neative emotional
responses and more emotional avoidance efforts in response to a positivel,
valanced film clip than did individuals not prone to panic :Tull < Roemer
>??7;5 thus these individuals ma, respond to all *inds of arousal s,mptoms
(ith an/iet, rather than discriminatin bet(een sources of that arousal.
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+onceptualization of +linical >
E +hristensen and Facobson :>???; note a similar process in couples. The, distinuish bet(een
initial problems :such as a difference in desired fre3uenc, of se/ual activit,; and reactive
problems :the difficulties that emere from each member of the couple4s attempts to cope (ith
this problem such as hostilit, (ithdra(al and accusation;.
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emotion conition and behavior. $ndividuals then learn to invalidate their
o(n e/pe- rience further contributin to their d,sreulation. The presence
of a udmental self- critical stance :and the absence of self-compassion;
can be seen as a causal or maintain- in factor in a (ide rane of presentin
problems :see 'eff Rude < Hir*patric* >??7 for evidence of association
bet(een self-compassion and ps,choloical (ell-bein;. %or instance (hen
individuals feel sad and become critical of their responses this nea- tive
vie( of themselves ma, decrease their motivation to ma*e behavioral
chanes or enae full, in their lives. $ndividuals (ith social an/iet,
commonl, enae in self- udment that ma, e/acerbate their fears ofothers4 udments reduce their (illinness to enae in various actions
(hen the, ma, be uded and increase their sense of bein unsafe in the
(orld due to some *ind of personal failin. Ma,a4s criticisms of herself for
e/periencin an/iet, e/acerbate her fears that she (ill be unsuccessful
heihtenin rather than lessenin her an/iet,.
Entangled or FusedAwareness
Broadl, acceptance-based models that emphasize mindfulness hihliht a
3ualit, of a(areness that leads to sufferin and contrast it (ith a 3ualit,
of a(areness that can be more freein. Accordin to these models (e
commonl, become 0hoo*ed1 into our internal e/perience partl, b, seein
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+onceptualization of +linical >@ Mindfulness-based models similarl, note the (a,s that approachin e/ternal events b,
udin or (ishin the, (ere other(ise leads to sufferin. 2e discuss this aspect of
mindfulness in the section on behavioral constriction.
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(e ma, ta*e this as an indication of her true lastin feelins. +onversel,
(e ma, ta*e our o(n transient e/perience of aner to(ard and absence of
affection for our partner as an indication of our true feelins and fear thatthe relationship is over. 2hen (e e/perience sadness and consider
ourselves defined b, this e/perience (e can develop a stimatized sense
of ourselves as damaed. This fusion bet(een our e/perience and our
perception of realit, ma*es internal e/periences particularl, po(erful and
li*el, underlies our desire for them to be other than the, are. $f the thouht
that our partner does not reall, care about us (ere ust a thouht that
(ould arise and fall naturall, and did not necessaril, reflect realit, it (ouldnot be so aversive and distressin.B
a,es and colleaues :e.. a,es Strosahl < 2ilson 6===; have
(ritten e/ten- sivel, about the role that conitive fusion ma, pla, in
ps,choloical problems and the process throuh (hich this fusion develops.
Relational frame theor, :R%T5 a,es Barnes-olmes < Rosche >??6;
suests that humans continuall, derive relations amon events (ords
feelins e/periences and imaes as (e enae (ith our environ- mentinteract (ith others thin* observe and reason. These relations result in
internal stimuli :e.. imaes feelins thouhts memories; ta*in on the
functions of the events to (hich the, are lin*ed. That is a memor, of a
painful event can elicit the same reac- tions as the event itself and
thouhts and feelins can provo*e reactions comparable to the e/ternal
conte/ts (ith (hich the, have been paired. Relational learnin has an
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+onceptualization of +linical E $t is important to note that thouhts do not have to be clearl, false for de"usion or
decentering to be beneficial. 2hile models underl,in conitive therap, often suest that the
irrationalit, of thouhts is central to clini- cal problems acceptance-based models emphasize
the problematic nature of relatin to thouhts in a specific (a, ta*in them as unchanin
realities rather than reactions to a iven moment. $n this conte/t a fused rela- tionship to athouht that accuratel, reflects a momentar, realit, (ould still be problematic in that it (ould
preclude a fle/ible choice-based adaptive mode of respondin.
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an, point (ould help alter the traector, and allo( for more fle/ibilit, in
behavioral respondin. Thus in this model critical neative a(areness
characterizes depression and the absence o" a more decentereddisentangled a(areness of this neative thouht pro- cess perpetuates it.
Studies have found that successful conitive therap, increases this
decenterin :Teasdale et al. >??>; suestin it ma, be an active
inredient in both conitive and acceptance-based behavioral interventions.
E#$ERIENTIAL A%OIDANCE
One of the most clinicall, relevant conse3uences of a fused entanled
relationship (ith internal e/periences is that it is li*el, to lead to riid
efforts to alter or avoid internal e/periences or experiential avoidance.
a,es Strosahl and 2ilson4s :6===; seminal (or* on the role of
e/periential avoidance in clinical problems provides an important corner-
stone for acceptance-based behavioral models. $n hihlihtin theimportance of consid- erin the function rather than the form of clinical
presentations a,es and colleaues suest that man, diverse clinical
problems can be understood as servin the function of e/periential
avoidance. Behaviors such as substance abuse and deliberate self-harm and
s,mptoms such as (orr, or rumination ma, all be strateies aimed at
alterin the form or fre3uenc, of internal e/periences :thouhts feelins
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+onceptualization of +linical E
of the behavior that preceded it. A commonl, held understand- in of
e/cessive substance use provides a particularl, salient e/ample of this
process :e.. Marlatt < 2it*ie(itz >??@;. Althouh substance use can have
numerous apparent neative conse3uences in the lon term it t,picall,results in an initial mood shift that
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is e/perienced as pleasant and stress reducin. This conse3uence is hihl,
reinforcin particularl, for individuals (ho e/perience a reat deal of
distress andDor have par- ticularl, neative reactions to their distress. Thusthe behavior is li*el, to continue althouh its lon-term conse3uences :e..
disruptions in relationships and other areas of functionin heihtened
tolerance (ithdra(al s,mptoms in the absence of use and the failure to
effectivel, process or resolve the distress that is habituall, avoided; all
perpetuate and increase distress. Similar models have been presented for
restricted eat- in :e.. effner Sperr, !ifert < &et(eiler >??>; and
deliberate self-harm :+hapman "ratz < Bro(n >??;. Ma,a4s pattern ofboth binein and restrictin her eatin fits this model. She describes an
initial reduction in an/iet, (hen she eats e/cessivel, but her an/iet,
increases as she beins to (orr, about her (eiht. She then restricts her
food inta*e aain lo(erin her an/iet, but ma*in her emotionall,
vulnerable due to reduced nutrition increasin her ris* of becomin
distressed and overeatin aain.
$n addition to the natural conse3uences that serve to maintain andperpetuate e/perientiall, avoidant strateies social forces li*el, maintain
these strateies as (ell. Althouh several ps,choloical :e.. a,es
Strosahl < 2ilson 6===5 Ma, 6==; and Buddhist :e.. +hodron >??6;
theorists have noted the ubi3uit, of emotional pain (e often et the
messae from other people that (e should be able to control our emotional
distress throuh sheer (illpo(er. Also it can seem to us that others are
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+onceptualization of +linical E
future; ma, in part function to reduce ph,sioloical arousal. Althouh (orr,
itself is a troublin internal e/perience that individuals often (ant to et rid
of studies have sho(n that (orr, actuall, serves a positive function b,
reducin ph,sioloical arousal in response to fearful imaes or situations:e.. Bor*ovec < u 6==?;. This neativel, reinforcin
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propert, of (orr, increases its fre3uenc,. People are li*el, to *eep
(orr,in because it has this relievin ph,sioloical effect even if the, are
una(are of that effect. o(- ever (orr, also perpetuates threateninassociations b, interferin (ith the complete processin of feared events.
Someone (ho is an/ious about socializin (ith co(or*ers at lunch ma,
decrease her arousal in this situation if she is preoccupied throuhout lunch
b, her (orries about an upcomin dental appointment but this prevents her
from learnin that althouh socializin (ith colleaues can elicit some
feelins of fear it can also be pleasant and fearful feelins diminish over
time. Ruminative processes in depressed individuals ma, serve a similarfunction reducin deeper levels of sadness and pain but maintainin
eneralized neative mood states.
+lients (ith a rane of clinical problems also enae more purposefull,
in efforts to avoid internal e/periences. %or instance individuals (ith
obsessiveJcompulsive dis- order describe their conitive rituals as a
strate, that reduces distress in the moment but the impairin an/iet, and
fear is maintained over time. +lients (ith posttraumatic stress disorderattempt to avoid thouhts feelins and memories associated (ith the
traumas the, have e/perienced. Althouh the, ma, ain some short-term
relief from these efforts the, find that the recollections return repeatedl,
perhaps more often because of these efforts to push them a(a,.
$ndividuals (ith substance dependence or abuse problems tr, to inore
thouhts and ures to use onl, to find them returnin more stronl,.
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+onceptualization of +linical E
model because riid efforts at e/periential control appear to have a host of
clinicall, relevant conse- 3uences suestin it is a useful taret for
intervention. Before describin these conse- 3uences in more detail it is
important to note that in certain conte/ts efforts to modif, internale/perience ma, not be problematic or harmful. #nfortunatel, the apparent
success of these strateies can fuel and maintain maladaptive efforts at
internal control.
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S*illful application of acceptance-based behavioral therap, relies on a clear
understand- in of the comple/ities of e/periential control and the conte/ts
in (hich tr,in to influ- ence our internal e/periences miht be beneficialversus harmful.
$n man, cases efforts to modulate our internal e/periences can be
beneficial. %or instance (e miht focus on our breathin prior to a public
spea*in enaement and find it reduces our heart rate slihtl, allo(in us
to present material more effectivel, to our audience. On the other hand
this focused breathin ma, have no effect on our heart rate or even
increase it. 2e miht find that (e *eep thin*in about a mista*e (e madeat (or* or somethin (e (ish (e had not said to a friend and choose to turn
our attention to a movie or a boo* in an effort to reduce our rumination. This
distraction miht lead to some relief or (e miht find that our minds return
to the event repeatedl, reard- less of (hat (e tr, to brin our attention
to. $f (e are able to allo( for the possibilit, of any of these conse3uences of
our behavior there is no harm in enain in actions that miht modulate
or alter our internal e/periences. 2hen the, (or* the, miht allo( us toe/pand our a(areness ain additional perspectives have ne( e/periences
and increase fle/ibilit,. $f (e can accept it (hen the, do not (or* (e can
continue livin our lives (ith the internal e/periences (e (ere unable to
alter.
Problems can arise (hen (e bein to tr, riidl, to eliminate or avoid
distressin internal e/periences and (hen this oal becomes a prominent
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+onceptualization of +linical E
e/pressions :%oa Ris Massie < )arczo(er 6==@; and those (ho report
hiher subective an/iet, ratins :reflectin hiher emotional enae- ment5
Fa,co/ %oa < Morral 6==8; in the first session of e/posure therap, achieve
better results from such treatment. Avoidance or distraction inhibits thisne( learnin of non- fearful associations. Thus e/periential avoidance is
li*el, to maintain distress rather
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than allo( emotional responses to run their course and ne( learnin to
evolve. Ma,a4s pervasive an/iet, ma, result in part from her repeated
efforts to suppress or limit her an/ious e/perience (hich li*el, interfere(ith the natural ebb and flo( of her an/ious and fearful respondin so that
she does not e/perience the natural decline that (ould accompan,
continued e/posure to threat cues.
!/periential avoidance can also interfere (ith other aspects of the
functional value of emotional responses. !motions provide important
information reardin our interac- tion (ith our environment tellin us
(hen our needs are bein th(arted (hen a threat is present or (hen (ehave lost somethin of value :e.. %rida 6=85 "reenber < Safran 6=875
Linehan 6==Ea 6==Eb;. Our emotional responses help us communicate our
needs to others in the form of e/pressions that occur rapidl, and
automaticall,. abit- ual riid avoidance of our emotional responses is
li*el, to interfere (ith our under- standin of our interactions (ith others as
(ell as of our o(n needs and desires. %or instance a client (ho is avoidin
his chronic feelins of sadness and disappointment b, distractin himself(ith alcohol miht be missin the information this sadness can provide him
such as his dissatisfaction (ith his current ob and a need to e/plore (a,s to
improve this situation or pursue another ob. Similarl, Ma,a4s constant
focus on her (or* is *eepin her from noticin the sadness and loneliness
that miht motivate her to cultivate her social and familial relationships.
!/periential avoidance can also affect our udments of or reactions to
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+onceptualization of +linical C
the clarit, of one4s internal a(are- ness ma*in it harder to respond
effectivel,. %or instance if Ma,a becomes anr, at her parents after the,
ma*e critical comments about her school performance but is uncom-
fortable (ith her aner she ma, onl, briefl, note her reaction and thenshift her atten-
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tion to(ard internal and e/ternal efforts to avoid this e/perience of aner.
As a result she (ill li*el, continue to feel activated and reactive in some
(a, but she ma, no loner be a(are of (hat prompted this reaction. Shema, misinterpret her response as more an/iet, (hich could hinder her
abilit, to chane the situation that elicited her aner. Thus reduced
limited or 0mudd,1 internal a(areness ma, be a result of habitual
e/periential avoidance.
%inall, e/periential avoidance often leads to behavioral avoidance or
behavioral enaement that interferes (ith individuals4 broader functionin.
$n addition to the more obvious costs :behaviors such as substance useovereatin or self-harm; e/peri- ential avoidance can subtl, impact
behavior b, preventin individuals from enain full, in their relationships
pursuin careers (ith meanin to them or effectivel, deal- in (ith
stressful life conte/ts. Aain riidit, is the central problemGefforts to
reduce distress ma, promote functionin in man, conte/ts but riid
avoidance efforts at the e/pense of life-enhancin oals ma, lead to
restricted unsatisf,in lives.
+EA%IORAL CONSTRICTION -FAILURE TO ENGAGE IN %ALUEDACTION
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+onceptualization of +linical C
that althouh clients feel the pain associated (ith their restricted lives
the, are not a(are of the role the, pla, in perpetuatin it.
Sometimes avoidance is evident in the 3ualit, of actions rather than
their occur- rence. %or instance in our (or* (ith clients (ith eneralizedan/iet, disorder (e have often found that the, seem to be enain in the
areas of life that matter to them :e..
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obs the, value spendin time (ith their children;. 2hen clients bein to
monitor their activities carefull, ho(ever it becomes clear that the, are
not full, present (hen the, are enain in these actions. $nstead the, are(orr,in about (hat ma, happen ne/t in another domain. Similarl, clients
ma, distract themselves or hold bac* emotionall, in certain conte/ts as a
(a, of avoidin distress from potential reection or hurt. %or instance &e/
a client (ho feared abandonment (ent throuh the motions of devel- opin
a ne( relationship but *ept himself distant emotionall, (hen he (as (ith
his partner as a (a, of avoidin this feared outcome. This distancin could
have provo*ed separation (hich he (ould have e/perienced asabandonment confirmin his fear and reinforcin the behavior. All of these
forms of disenaement can limit clients4 satisfac- tion and success in
various areas further drivin e/periential avoidance and perpetuat- in
distress.
Another (a, in (hich clients miht unintentionall, diminish their
satisfaction is b, appl,in the same udmental riid (a, of respondin to
e/ternal situations as the, do to their internal e/perience. Acceptance- andmindfulness-based approaches hihliht the role that udment of e/ternal
events can pla, in sufferin. Repeatedl, (ishin that thins (ere other than
the, are :e.. one4s partner (as different one4s colleaues (ere different;
can prolon distress and interfere (ith effective action. Linehan :6==Eb;
ives the e/ample of choosin to become stuc* in an anr, and frustrated
state (hen drivin behind someone (ho is oin too slo(l, in the fast lane
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+onceptualization of +linical C
clarif,in internal a(areness to counter the restricted or occluded
a(areness that individuals often e/perience. $n addition an emphasis is
placed on cultivatin a nonudmental compassionate relationship (ith
e/periences as the, arise to reduce reactivit, fear and
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udment (hich have been found to increase distress motivate e/periential
avoidance and interfere (ith functionin. %inall, this oal includes
cultivatin an e/perience of thouhts feelins and sensations as naturall,occurrin and transient and reducin an e/perience of them as indicators of
a permanent truth. %or instance Ma,a (ho habitu- all, e/periences
ph,sioloical sensations of an/iet, and interprets these as evidence of her
frailit, vulnerabilit, and inabilit, to cope (ould enae in a rane of
practices desined to help her notice the sensations as the, arise feel
compassion for herself for e/periencin them see them as overlearned
ph,sical sensations that elicit a rane of reactions but that do not defineher and e/pand her a(areness to notice other e/peri- ences and
sensations that co-occur (ith an/iet, as (ell as the (a, that an/iet,-related
sensations subside over time.
Several t,pes of interventions can be used to assist in meetin this oal.
Psycho# education :described in depth in +hapter @; helps clients
understand the nature of inter- nal e/periences :specificall, the function of
emotions; and the role that these t,pes of relationships to internal eventscan pla, in sustained distress and restrictions in their lives. Sel"#monitoring
can help enhance clients4 a(areness of their internal e/periences especiall,
the (a, these e/periences rise and fall and their connection to conte/ts and
behaviors. #nderstandin is not sufficient for chanin these
overlearned deepl, inrained relationships. Therefore sinificant time is
devoted to a rane of experiential practices that assist in cultivatin ne(
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choose responses rather than reactin. Monitorin helps clients see ho(
e/periential avoidance affects their lives and identif, earl, cues to
conte/ts in (hich to practice an acceptin rather than avoidant response.
Mindfulness- and acceptance-based prac- tices help develop the s*ill ofacceptance increasin clients4 fle/ibilit, in the (a,s the, respond to
conte/ts that elicit intense reactions.
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%inall, ABBTs emphasize the oal of increasing valued action. This
includes refrain- in from actions that ma, be ver, temptin in the
moment :often because the, serve an e/perientiall, avoidant function; butare not in line (ith the (a, the client (ants to live his or her life and
enain in actions that matter to the individual but have been avoided.
$mportant components of this oal include identif,in and clarif,in (hat
matters to the individual brinin a(areness to moments (hen choices
could be made based on these values and enain in action in desired
directions.
All the methods that promote the first t(o oals also serve this oal inthat ena- in in chosen action is facilitated b, an unentanled defused
relationship to one4s e/pe- rience and an abilit, to choose a
none/perientiall, avoidant response. $n addition ps,- choeducation and
monitorin help brin a client4s attention to (hat is important to him or her
to set the stae for chosen action. 2ritin e/ercises serve to clarif, values
as does mindfulness practice. 'onreactive decentered a(areness can allo(
one to re"lectively see (hat matters rather than re"lexively endorsinvalues based on societal pressure or fears :Shapiro +arlson Astin ??;. %inall, bet(een-session behavioral e/ercises in (hich
actions are chosen and planned for enaed in and revie(ed allo( clients
to e/pand their behavioral repertoire and enae more full, in their lives.
These behavioral chanes often elicit ne( t,pes of problematic relationships
(ith internal e/periences and impulses that promote e/periential
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Tw"
+linical Assessment of Relevant
&omains
The first step to (or*in (ith a client from an acceptance-based behavioral
perspec- tive is to conduct a comprehensive assessment of the nature and
e/tent of the client4s presentin problems ps,choloical status attitudes
to(ard internal e/periences :e.. emotions ph,sical sensations; common
copin strateies :includin e/periential avoid- ance; 3ualit, of life and
previous e/perience in treatment 'ot onl, is a careful and s,stematic
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(e focus on measures (e find to be hihl, applicable :in that the, assess
constructs that are important and meaninful to the client and that uide
treatment; acceptable :brief and user-friendl,;practical :minimal
EC
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+linical Assessment of Relevant E
cost eas, to score and interpret; and psychometrically sound :reliable
valid and sensi- tive to chane;.
S/.$TO.0+ASED
ASSESS.ENT +r"a) O(er(iew "f $resentin1
C"ncerns
2e start the assessment process b, tr,in to et a sense of the client4s
presentin con- cerns desired life directions and current factors that
motivated him or her to see* treat- ment. T,picall, this initial report (ill
include a description of ps,choloical s,mptoms :e.. difficult,
concentratin h,perarousal; current emotional state :e.. sad an/ious
anr,; and difficulties in functionin that are impactin 3ualit, of life :e..
interper- sonal conflicts problems at (or* diminished ph,sical health and
(ell-bein;. Persons :6=8=; and 2ood, and colleaues :>??E; suest that
earl, in the assessment period clinicians develop a comprehensive problem
list (hich can be used to identif, priori- tize and manae all of the client4s
current difficulties. %or e/ample &ere* initiall, pre- sented (ith complaints
about depression includin depressed mood fatiue difficult, sleepin
decreased appetite and difficult, concentratin. e also noted that he (as
3uite irritable both at (or* and (ith his partner. is partner (as also
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FIGURE 2343 &ere*4s problem list.
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+linical Assessment of Relevant E
to propose an underl,in mechanism that accounts for the problems
enumerated on the problem list and tie them toether in a (a, that (ill
uide treatment.2e also ma*e an effort to learn about the client4s cultural identit,. A
culturall, sensitive approach to assessment is aimed at ensurin that the
client4s problems are accuratel, understood and defined ta*in into
account cultural norms and e/pecta- tions informin the development of an
appropriate treatment plan that ade3uatel, meets the needs of the client
and demonstratin respect for the client4s culture in an attempt to promote
a stron therapeutic alliance :Tana*a-Matsumi Seiden < Lam6==;. The therapeutic relationship is a critical component of ABBT that is
assumed to foster an environment in (hich the client can bein to develop
a self-acceptin and self- compassionate stance. ABBTs re3uire a sinificant
commitment on the part of the client as e/tensive bet(een-session practice
(ith mindfulness and valued actions is encour- aed. $n our e/perience a
stron therapeutic relationship increases enaement in and compliance
(ith therapeutic activities.As discussed in more depth in +hapter 66 understandin a client4s
cultural iden- tit, can inform man, facets of ABBT. +ultural factors can pla,
a sinificant role in ho( one vie(s one4s emotions ho( emotions are
vie(ed b, one4s famil, members and the t,pes of values :e..
individualistic or interdependent; that are personall, held. Atten- tion to
ho( e/ternal forces such as economic disadvantae and oppression affect a
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%rom this perspective (e (elcome and e/pect clients (ho feel both
disconnected from the re(ards associated (ith ma*in a life chane and
painfull, a(are of the obstacles to ma*in this chane to present (ithambivalence. The oal of ABBT is to increase the salience of positive
re(ards of chane b, helpin clients access (hat is person- all,
meaninful about their oals for treatment and decrease the size and
manitude of obstacles b, chanin the relationship clients have (ith their
internal e/periences.
Once (e have a broad overvie( of these presentin issues (e delve
deeper into the assessment process b, more s,stematicall, assessin avariet, of domains.
$s!ch"&ath"l"1!
a,es and his colleaues :6==; criticized the (idel, held medical
s,ndromal model of ps,chopatholo, citin the hih rates of comorbidit,lo( treatment utilit, and fre- 3uent irrelevance of the dianostic model to
the t,pes of presentin problems t,picall, seen in clinical practice. As an
alternative he and his colleaues proposed a dimen- sional functional
approach to ps,chopatholo, that assumes that man, forms of ps,-
chopatholo, are best conceptualized as e/periential avoidance. 2hile (e
support this perspective for a number of practical and clinicall, relevant
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There are also a number of lobal and s,mptom-specific 3uestionnaires
that can be used to provide more information about the nature and severit,
of ps,choloical s,mp- toms e/perienced b, the client. The &epression
An/iet, Stress ScalesG>6-$tem 9ersion :&ASS->65 Lovibond < Lovibond6==@; is a >6-item measure that ,ields separate scores of depression
an/iet, :i.e. an/ious arousal; and stress :e.. tension;. The Brief S,mp-
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+linical Assessment of Relevant C
tom $nventor, :BS$5 &eroatis < Spencer 6=8>; can also be a useful
3uestionnaire mea- sure for assessin overall ps,choloical distress. The BS$
provides information about a client4s s,mptom report on nine primar,s,mptom dimensions and ,ields three more lobal indices of ps,choloical
functionin.
$"tentiall! armful+eha(i"rs
!naement in self-inurious and impulsive behaviors such as deliberateself-harm :e.. cuttin burnin; substance misuse unsafe se/ual
practices and compulsive spend- in amblin and eatin can be a form
of e/periential avoidance that is important to assess. %or man, clients
these behaviors are also associated (ith sinificant shame (hich means
the, are fre3uentl, underreported. $t can be clinicall, useful to routinel, as*
clients (hether or not the, use alcohol drus food or potentiall,
danerous activi- ties as a (a, to cope (ith their emotional pain. &irectl,as*in about embarrassin and ris*, behaviors in a matter-of-fact (a,
demonstrates acceptance and validation and increases the probabilit, that
clients (ill be (illin to disclose such information.
$t can also be useful to overestimate the fre3uenc, of potentiall,
harmful behaviors durin 3uestionin to et a more accurate self-report. %or
e/ample durin a phone screenin a client named Rochelle (as as*ed
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abilit, that he (ould be rehospitalized. &urin an assessment meetin
Anel4s ne( therapist shared his vie( that people enae in all sorts of
behaviors that the, *no( are harmful because the, find their emotional
pain so intense. The therapist normalized suicidal thouhts b, suestinthat suicide often seems li*e the onl, option to someone
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(ho is in sinificant distress. e encouraed Anel to tal* openl, about his
thouhts and feelins and offered Anel the possibilit, that he could learn
ne( problem-solvin s*ills :e.. acceptance and tolerance of emotionalpain behavioral activation; throuh ABBT as an alternative to suicide.
A number of individual and situational factors should be assessed to
inform the cli- nician of the potential tarets for treatment to decrease
suicidalit, includin conitive st,le :e.. infle/ibilit,; problem-solvin st,le
:e.. deficit in s*ills; emotional pain and sufferin emotionall, avoidant
copin st,le interpersonal deficits self-control deficits and environmental
stress and support :+hiles < Strosahl >??@;. The Reasons for Livin$nventor, :Linehan "oodstein 'ielsen < +hiles 6=8E; can be used to
measure a rane of beliefs :social and copin beliefs responsibilit, to
famil, child-related concerns fear of suicide fear of social disapproval and
moral obections; that ma, be important in preventin a client from
attemptin suicide.
RELATIONSI$ TO INTERNAL
E#$ERIENCES Awareness "f Em"ti"nal E'&erience
A critical part of our assessment involves e/plorin the client4s
relationship to his or her internal e/periences :e.. emotions thouhts
internal sensations;. %irst (e pa, attention to the level of a(areness and
ifi i i h hi h li d ib h i i l f li
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(hen ma*in a numerical ratin.
Similarl, clients are often una(are of specific situational triers that
elicit par- ticular emotions. Once aain individualized self-monitorin
sheets can be developed
+li i l A t f R l t C
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+linical Assessment of Relevant C
to better assess these domains :see %orm >.> p. @>;. %or e/ample a client
can be as*ed to notice the emerence of t(o or three stron emotions each
da,. 2hen the client e/peri- ences one of those emotions he or she can beas*ed to note the da, and time the situa- tion the emotion elicited and
an, accompan,in thouhts or ph,sical sensations.
2hile an intervie( and self-monitorin ma, reveal difficulties in
identif,in and describin emotions there are also 3uestionnaires that
assess this response st,le. %or instance the T(ent,-$tem Toronto
Ale/ith,mia Scale :TAS->?5 Bab, Par*er < Ta,lor
6==C; is a 3uestionnaire that measures the construct of ale/ith,mia.Ale/ith,mia is char- acterized b, difficulties identif,in and describin
emotions a tendenc, to minimize emotional e/perience and a pattern of
focusin attention e/ternall,. $tems such as 0$ am often confused about
(hat emotion $ am feelin1 and 0$ often don4t *no( (h, $ am anr,1 are
rated on a @-point scale ranin from 6 :0stronl, disaree1; to @ :0stronl,
aree1;. The TAS->? ,ields an overall score and scores for three subscales
&ifficult, &escribin %eelins &ifficult, $dentif,in %eelins and !/ternall,Oriented Thin*in.
The &ifficulties in !motion Reulation Scale :&!RS5 "ratz < Roemer
>??C; is a
E-item measure that can provide comprehensive information about
various aspects of
a client4s emotion reulation :discussed in more depth belo(;. T(o
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rated on a
-point scale ranin from 0almost al(a,s1 to 0almost never.1 2hile this
measure is
helpful in assessin a(areness it does not tap into man, of the other
important ele-
ments of
mindfulness.
Several other measures of mindfulness are desined to capture more of
its facets.
%or instance the %reibur Mindfulness $nventor, :%M$5 Bucheld "rossman
< 2alach
>??6; is a E?-item 3uestionnaire that assesses nonudmental present-
moment obser-
vation and openness to neative e/periences. The Hentuc*, $nventor, of
Mindfulness
S*ills :H$MS5 Baer Smith < Allen >??C; is a recentl, developed E=-item
scale desined
+linical Assessment of Relevant C
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+linical Assessment of Relevant C
to measure four of the five aspects of mindfulness described above
observation description actin (ith a(areness and acceptin (ithout
udment. There is also pre- liminar, support for the development of a E=-item measure the %ive %acet Mindfulness Nuestionnaire :%%MN5 Baer et al.
>??; (hich includes items from all of the measures described above.
Fusi"n with InternalE'&eriences
The model drivin ABBT proposes that bein fused (ith or hoo*ed b, ,ourinternal e/periences drives attempts at e/periential avoidance. Thus one of
the oals of ther- ap, is to help clients decenter or defuse from their
thouhts emotions imaes and ph,sical sensations. One potentiall,
useful (a, to assess an individual4s fusion (ith his or her o(n thouhts
and feelins is to as* him or her to rate the believabilit, of different
thouhts and internal e/periences that arise. 2hile there are no eneral
mea- sures to assess this construct researchers have developed content-specific measures that as* individuals to rate the believabilit, of the content
of depressive thouhts :Iettle < a,es 6=87; hallucinations and delusions
:Bach < a,es >??>; and stimatizin atti- tudes :a,es Bissett et al.
>??C;.
The ThouhtJAction %usion Scale :TA%S5 Shafran Thordarson ??@;.
There are several methods one can use to assess sleep 3ualit,. ThePittsburh Sleep Nualit, $nde/ :PSN$5 Bu,sse Re,nolds Mon* Berman ;. $n addition to
these 3uestionnaire measures a sleep diar, in (hich participants self-
monitor their dail, sleepD(a*e patterns has been sho(n to be a reliable
assessment instrument :Roers +aruso < Aldrich 6==E;.&iet and e/ercise are also important components of 3ualit, of life (orth
assessin. !ven (hen eatin concerns are not a presentin problem poor
nutrition and erratic eatin patterns can threaten a client4s health and (ell-
bein. Se/ual functionin is often overloo*ed as a component of 3ualit, of
life. A lare epidemioloical surve, conducted in the #nited States
:Laumann Pai* < Rosen 6===; found that CE of female and E6 of male
respondents e/perienced some form of se/ual d,sfunction. Problems inse/ual functionin can neativel, impact mood and strain intimate
relationships. Althouh man, clients are uncomfortable discussin their
se/ualit, (e have found that it can be 3uite normalizin to as* about
satisfaction in this important life domain as part of a comprehensive
assessment of 3ualit, of life. %urthermore a 3uestionnaire such as the
&eroatis Se/ual %unctionin $nventor, :&S%$5 &eroatis < Melisaratos
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currentl, out of (or* on disabilit, due to s,mp- toms of M&& and (ho hihl,
values bein challened and contributin in the (or*- place miht rate this
domain as hihl, valued and inconsistentl, pursued. +lients (ith this profile
are li*el, to report sinificant ps,choloical distress and to appear immobi-lized (ith reard to movin for(ard and ma*in chanes in valued domains.
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Another pattern (orth notin is one of e/tremel, lo( importance scores
across most or all valued domains. %or instance a client (ho is e/tremel,
isolated (ith a histor, of social reection miht uniforml, rate famil,intimate relations parentin and friendship as all unimportant. Sometimes
this pattern of 0not carin1 ma, actuall, reflect a desire to avoid the pain
associated (ith ac*no(ledin a (ish to be connected (ith others :2ilson
< Murrell >??C;. $n these cases the clinician can entl, e/plore if 0not
carin1 is preventin the client from pursuin these important life domains.
A final notable pattern is that of e/tremel, hih total importance and
consistenc, scores. Particularl, (hen a client reports little ps,choloicaldistress such endorse- ment ma, reflect the client4s desire to present him-
or herself in a sociall, acceptable (a, :2ilson < Murrell >??C;. $n our o(n
practice (e have seen a number of clients (ho endorse man, values as
hihl, important and report that the, are consistentl, act- in in
accordance (ith these values but describe sinificant ps,choloical
distress. $n these cases clients are often 0oin throuh the motions1 of
livin a valued life (ithout brinin mindfulness to their e/periences. %ore/ample 2end, (as a professional (ith an e/citin and challenin career
a solid marriae and three (onderful children. On the surface she seemed
to be stri*in a balance bet(een succeedin in her career and spendin
3ualit, time (ith her famil,5 ho(ever upon more careful intervie(in it
became apparent that 2end, (as not brinin mindfulness and intention to
her behav- ior in valued domains. 2hen she (as at (or* althouh her
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the, are as*ed to thin* about (hat it means be a ood friend and iven
possible descriptions to consider such as bein supportive considerate
carin acceptin lo,al or honest; and then as*ed to articulate an,
personal values the, ma, have in this domain. 'e/t clients are presented(ith nine 3uestions about the value each rated on a @-point scale that
assess motiva-
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tion for holdin the value the e/tent to (hich behavior is currentl,
consistent (ith the value commitment to the value importance of the
value and (hether or not it is a potential area for improvement.Lundren &ahl and a,es :>??8; have developed the 9alues Bull4s
!,e a measure of values attainment and persistence (hen encounterin
barriers usin a series of four pictorial representations of dartboards. The
first three dartboards are used to assess the e/tent to (hich clients are
livin consistent (ith their values. The client is as*ed to describe three
deepl, held personall, relevant valued directions that he or she (ould li*e
to (or* on in therap,. The center of the dartboard :the bull4s e,e;represents livin full, in accord (ith that value and the client is as*ed to
mar* ho( close to the bull4s e,e he or she is currentl, livin. A fourth
dartboard is used to assess persistence of actin in accordance (ith values
in the face of ps,choloical barriers such as an/iet, or sadness. The client is
as*ed to (rite do(n individual barriers that ma*e it difficult to live consis-
tent (ith his or her values then to indicate persistence of valued action in
the face of the described barriers :(ith the bull4s e,e meanin the client
al(a,s persists;. The distance bet(een the center :bull4s e,e; and the ede
of all four dartboards is C.@ centimeters and scores representin the
distance bet(een the mar* and the bull4s e,e can var, from ? to C.@ (ith
lo(er scores e3ualin reater attainment or persistence. 9alues attainment
is a mean of the first three dartboards5 persistence throuh barriers is
enerated b, the sinle measure.
h d f d ibl i h h i h
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approaches dra( from and are compatible (ith +BT techni3ues such as
self-monitorin e/posure therap, behavioral activation and s*ills trainin.
Some (a,s of approachin irrational thouhts (ith conitive restructurin
are consistent (ith the ABBT oal of chanin
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the relationship that the client has (ith his or her internal e/periences. %or
e/ample encourain a client to consider his thouhts as merel, thouhts
and not facts to attend a part, even (hen he is feelin an/ious and toobserve (hat reall, happens in that feared situation miht be part of both
approaches to treatment. $n contrast other coni- tive approaches ma,
focus more on chanin the content of a specific thouht in order to
decrease an/iet, (hich is less consistent (ith an ABBT perspective. %or
e/ample a client (ho is an/ious at parties ma, be as*ed to tr, and replace
the thouht 0$ feel li*e a fool because $ am not as educated as the other
people here1 (ith somethin li*e 0$ am an interestin and educatedperson.1 The rationale of +T in this case (ould be to reduce the fre3uenc,
and intensit, of uncomfortable thouhts (hich (ould be e/pected to
decrease an/iet, and facilitate e/posure to feared situations. Althouh
s,mptom reduc- tion is an obvious oal of ABBT the emphasis in this
approach is on developin an acceptin and compassionate stance to(ard
oneself and enain in actions that are consistent (ith personall, relevant
values.
As conitive-behavioral approaches have ro(n in popularit, the term
has come to describe a much broader class of disparate techni3ues.
Therefore (e find it useful to as* our clients more specificall, about (hich
elements of +BT the, received :e.. ps,choeducation conitive
restructurin behavioral activation s*ills trainin rela/- ation trainin
e/posure therap,;. %urthermore if the, report that certain techni3ues (ere
:SA&; d h d th t t b d h t
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:SA&; and he e/pressed concern that an acceptance-based approach to
treatin his "A& s,mptoms (ith the current therapist (ould be inconsistent
(ith the (or* he had completed. 2e (ere able to dra( parallels for him
bet(een the self-monitorin he completed and the develop- ment of the
mindfulness s*ill of attention. %urthermore (e discussed the consistencies
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bet(een no loner acceptin certain thouhts as facts and the decenterin
and defusion s*ills of mindfulness. Rather than directl, confrontin Mar*
about (hether chanin the content of his thouhts (as necessar, fortreatment (e as*ed him if he (as (illin to e/pand his repertoire and tr,
some ne( approaches to cope (ith his emotions (hen conitive
restructurin (as ineffective.
N"n)irecti(eTreatment
2hile the acceptance and validation aspects of ABBT are 3uite consistent
(ith man, nondirective humanistic approaches to therap, the behavioral
elements of ABBT that re3uire sinificant out-of-session activit, are not as
common to these approaches. $t can be ver, useful for the clinician to
*no( about a client4s previous e/perience and satisfaction (ith nondirective
therapies as such a histor, can definitel, affect a client4s oals and
e/pectations for treatment. %or e/ample Richard souht treatment (ith one
of us :Orsillo; after terminatin (ith a humanistic therapist he had been
seein for appro/imatel, >? ,ears. At first Richard (as put off b, the
suestion that therap, (ould re3uire out-of-session (or* statin that he
had done home(or* (hile he (as in school and he did not see the need for
home(or* in therap,. $ spent considerable time (ith Richard in an effort to
provide an ade3uate and compellin rationale for out- of-session practice. A
therap, she and her therapist spent some time revie(in their proress
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therap, she and her therapist spent some time revie(in their proress
and noted that Shoshanna (as strulin sinificantl, (ith the mindfulness
concepts of self-compassion and accep- tance. Because the therapist did
not full, assess Shoshanna4s past e/perience (ith medi- tation she (as
una(are that Shoshanna had little practice (ith these s*ills.
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TA+LE 2343 A))iti"nal AssessmentRes"urces
Author:s; :,ear; %orm &omain
Reprints
measures
Anton, Orsillo< Roemer:>??6;
Boo* An/iet, )es
'ezu RonanMeado(s< Mc+lure :>???;
Boo* &epression )es
+ocoran ???;
Boo* Broad spectrum ofps,choloical constructs
)es
Association for+onte/tualBehavioral Science
2ebsite :www.contextualpsychology. org;
9ariet, of A+T-relatedassessment instrumentsincludin man, that currentl,under development
)es
Buros $nstitute ofMentalMeasurements
2ebsite:www.unl.edu'buros;
"eneral and comprehensive listin of 'ops,choloical instruments
ADDITIONAL ASSESS.ENT RESOURCES FOR TE CLINICIAN
FOR.2 4
http://www.unl/http://www.unl/http://www.unl/http://www.unl/http://www.unl/http://www.unl/http://www.unl/http://www.unl/http://www.unl/http://www.unl/8/13/2019 01 Conceptualizacin y Evaluacin (2)
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234AN#IET/ AWARENESS SEET
Please rate ,our an/iet, :on a scale of ? to 6?? (ith ? bein no an/iet, at all
and 6?? bein severe an/iet,; at four different times durin the da,. $f ,ounotice an,thin (hile ratin ,our an/iet, feel free to ot do(n these
observations belo( the form.
Ratin1Scale- ? @? 6??
'o an/iet, atall completel,
rela/ed
Moderate an/iet, Severe an/iet,
&ate
Mornin
'oon
TimeDRati
!venin
'iht
TimeDRati
@6
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@> FOR.232
E.OTION .ONITORING SEET
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2hen ,ou notice that ,ou are e/periencin a stron emotion please ta*e a moment to notice and (rite do(n the
situation ,ou are in and the emotion ,ou are e/periencin. Please also record an, thouhts ,ou are havin at that
time and an, ph,sical sensations :e.. heart racin muscle tension fatiue;.
&ateDTime Situatio !motio Thouht Ph,sical
%rom Lizabeth Roemer and Susan M. Orsillo :>??=;. +op,riht b, The "uilford Press. Permission to photocop, this form is ranted topurchasers of this boo* for personal use onl, :see cop,riht pae for details;.
FOR.235
ASSESS.ENT OF CO$ING STRATEGIES
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@E
As ,ou have been doin please continue to notice stron emotions that emere in different situations and the
thouhts and sensations that accompan, each emotion. Also note ho( ,ou respond to the emotion :e.. pa,
attention to it tr, and push it a(a, distract ,ourself tr, and chane it etc.; and the outcome :successful
unsuccessful feel better feel (orse etc.;.
&ateDTim Situation !motionsDThouhtsDSensatio Response Outcom
%rom Lizabeth Roemer and Susan M. Orsillo :>??=;. +op,riht b, The "uilford Press. Permission to photocop, this form is ranted topurchasers of this boo* for personal use onl, :see cop,riht pae for details;.