ACT Session Checklist

What is it?
The attached Word files are intended for ACT Clinicians to monitor their fidelity to the treatment principles of ACT. This is done by rating the therapist's practice immediately after each session.

Essentially the "ACT Core Competency Session Rating Form" is a less wordy form of the Core Competencies self rating form. The difference is that this form I've uploaded has very brief, generally three-word, descriptions of the items from the Core Competencies Self Rating Form. If you want to see how each item in the "Session Rating Form" corresponds to the ones in the "Competencies self rating form", read the "ACT Core Therapeutic Session Checklist Cross reference" file below. The Session rating form also has a checkbox for each session so that the sheet can be used for ten sessions with the one client.

How does it work?
You can score it in a number of ways. Here are some examples:

1. Check mark or cross in the box for presence of the dimension/behavior;
2. Check mark or cross for absence of the dimension/behavior;
3. Combination of both of the above - check for presence, cross for absence, dash for neutral or not applicable;
4. Score from say, 0 to 10 for degree/quality/frequency of the dimension/behavior.

Obviously if you're using this for research or for practitioner training, evaluation or supervision, you need a consistent approach across sessions and clients.

N.B. US version is for Letter sized paper, UK version for A4.

Why did you do it?
I haven't had the opportunities that many ACT practitioners have had of being immersed in an ACT-focused research program or of attending a Summer Institute or World Conference. Consequently I've been trying to improve my ACT practice without the benefit of observational 'live' supervision.

I've used this kind of self-monitoring sheet when learning other therapeutic approaches and found it very helpful. Using this kind of self-monitoring session rating sheet is one way I believe, of achieving expertise through effortful practice (see page 27 especially).

What's next?
If you download the session rating form and use it, please post your opinions, comments, suggestions for change/revision and findings here. If you have an extended comment or heaven forbid, actually use it in research or formal practitioner training, I'd suggest making a child page here.

As well, I'd ultimately like to see the 60-odd items here reduced to a manageable 12 or less. Workability of the tool will ensure its use. Parsimony, validity and reliability are essential.

The attached spreadsheet gives some idea of the direction in which I think this endeavour could develop. I've proposed six 'global dimensions' of in-session therapist behavior. They are Structure, Flexibility, Workability, Presence, Precision and Compassion.
These dimensions are not the same as the dimensions of the Hexaflex because the Hexaflex describes processes and I am attempting to describe either therapist traits or if you like, 'therapist qualities demonstrated in session'. Clearly though there is some degree of overlap - Being Present with Presence, and Acceptance with Flexibility (but also with Compassion).

I've developed these 'global dimensions' to give the therapist some 'touchstones' or compass points for their own practice. I welcome practitioners', trainers' and researchers' comments on any of these documents.

Business Card Behavioral Analysis

I've been using a process with both group, couple, and individual
> clients that seems to work pretty well. I stumbled upon this, but I'm
> sure it's been thought of before. If someone has refinements, I'd
> love to hear it.
>
> I've been using the back of old business cards to conduct a chain
> analysis of behaviors with clients. Business cards seem to be just
> the right size for this, as you can't really put much on them. I have
> the clients write down all of the pieces of the situation, behavioral
> chain, what have you, and then they lay them out.
> the cool thing is, sometimes they'll lay out two cards that seem to
> have a lot more to them, and I can challenge them to make sure
> there's no more steps. For example, my mother calls me on one card, I
> want to die, on the next.. We can tease apart all of the behavioral
> steps in the chain, group different parts together, shift them
> around, add new or different steps, change the order.
> It seems to work pretty well for defusion and self as context. At the
> end of the session, clients take their business card chains home with
> them, and bring them back to session the next time. We talk about
> walking even with the cards in their pockets.
> It's fun.

Core Processes/Metaphors Tracking

Core Processes/Metaphors Tracking
Have you ever had this situation: You are meeting with your sixth patient of the day and, in the therapeutic moment, you see a perfect opportunity to present a particular ACT metaphor....but you can't quite remember if you had done that other metaphor which sets the stage for this one.....and you ask "have we talked about the person in the hole yet?" Now, many of the perfect therapists on this list surely would never do this. However, for the rest of us, how do you keep track of what you have covered?

I designed the attached form (see bottom) for jotting down what I have covered. I sometimes review it prior to sessions along with progress notes from those earlier sessions. Now, granted, I still occasionally check-in about whether we covered an exercise/metaphor (no big deal), though less often and less awkwardly. You will note that the exercises and metaphors often target multiple core processes, so this form is just a coarse tracking guide. But I find it helpful.

Content of the Attachment
Page 1 is the form. Page 2 is an example of what it might look like after multiple sessions (metaphors/exercises would be hand-written, of course). Upon review, the sample on Page 2 contains far more actual content than the completed forms I have used with patients.

Using the Form
Time proceeds from middle (1st session) to out (in my use of it). Going from out to in results in much crowding of the content in the middle. It also makes it more difficult to get a sense for the progress of therapy (at a glance).

Using the Form for Self-Assessment
The form can also be used as a tool for ongoing self-assessment, revealing your therapy habits. For example, even a casual glance at some of my completed forms quickly revealed that I favor Values work and Cognitive Defusion, using a handful of mindfulness techniques, mostly for getting clients and myself into the Present Moment, less so in the service of promoting Self-As-Context. While this evident pattern may merely reflect my personal style in using ACT, it also challenges me to do some self-examination about processes that I may avoid (one's style is always
a work in progress, right?). I also find it useful to compare completed forms to my responses on the ACT Core Competency Self-Assessment, an excellent learning tool available on this site.

Improvements and Revisions
Feel free to edit, change, and improve the Core Processes/Metaphors Tracking Form to fit your needs. If others have similar tools/guides or improve upon this form, please share the work!

A brief introduction to ACT from the March 5, 2007 issue of the Sunday Telegraph in the UK

See attachment below

A short introduction to ACT to be handed out after a first session

Russ Harris has this to say about the form which is attached below:

I've attached a word doc of a brief summary of ACT that I give my clients on the first session. Anyone can easily re-edit it to suit their clientele. (I also usually give them a copy of the "Embracing your Demons" article; it's pitched at a level the average layperson can understand.)

ACT in plain language

ACT in plain language
Submitted by Joel Guarna on February 1, 2006 - 10:38pm.

I agree that explaining ACT plainly is difficult. With my clients, I often compare and contrast ACT with CBT more generally, since CBT is more widely known. I discuss similarities and refer to some common roots to both. I then illustrate some contrasts to traditional CBT by saying that an ACT approach is "not so much about changing the content of thinking (give examples, +/- thinking, etc) or fixing 'distortions' as about changing your relationship to your thoughts, feelings, memories, and other so-called private events (relate these to their presenting issues). ACT is less about making anxiety or depression go away and more about getting you untangled from the thoughts, feelings and rxns you have and getting you (client) moving in a direction that is important to you."

I give a very lay summary that ACT is related to a basic science and theory about human language and thinking (I do NOT attempt to explain RFT in much detail) and their role in our suffering (I sometimes give examples of our pain/suffering and how it differs from nonverbal animals...if the client seems interested and appears to be following). I add that, since human language seems to complicate our dealing with private events, doing ACT as a "talk therapy" is tricky: "so, if you are up for it, we will use a lot of exercises, mindfulness practice, metaphors, and other methods to keep us both from getting tangled up in the words and ideas." I try to relate all of this to their personal issues as much as possible and use examples. I discuss this in "we" terms throughout.

Once their interest is piqued (& it usually is) and I am satisfied they have a sufficient grasp on the approach to give informed consent, I implore them to hold whatever "understanding" of this that they now have VERY lightly. I then try to back out of all this wordiness and shift back into a more experiential mode. The process is a difficult balancing act b/n providing enough info for informed consent and getting ahead of ourselves and getting too didactic and wordy.

ACT orientation diagrams

In case they are of use to anyone, I am attaching a couple of ACT orientation diagrams - variations on a theme really.

I hasten to say that these are not in any way intended to challenge the Hexaflex. Rather, they are intended for use with clients (or colleagues etc) to give a quick introduction or summary of what ACT is all about. Perhaps they might also have a role in therapy (individual or group), say in aiding discrimination training (e.g., "whereabouts on the diagram are you now?").

Get Out of Your Mind and Into Your Life (4x4) diagram:

Steve was kind enough to look at an earlier draft of this diagram which, as the name suggests, is intended to provide an overview of the book. Perhaps it could also be used as a structure for collecting client examples (e.g., pain, unworkable control attempts, etc). (I nicknamed it 4x4 because of the 4 circles and 4 arrows and it's quicker to write in the notes!) The 4 arrows of course represent 4 of the hexaflex processes, being the ACT skills enabling the client to get out of their mind (lower circles - pain/ struggle > suffering) and into their life (upper circles - values/ commitment > action).

(Putting this together made me wonder if the sequence of the arrows could suggest a sequence for the teaching of ACT skills, each building on the previous one - i.e., being in the present moment facilitating the observer perspective - in turn facilitating defusion - in turn facilitating acceptance.)

Four Cycles diagram:

Similar idea but generally a bit more detailed, though amalgamating the "self-as-context" and "being present" processes in a single "noticing" item (and a similar amalgamation - "Overthinking" - in the Struggle cycle). In this one the pivot point is in the middle ("Pain") and from there you either shuttle round the Struggle and Suffering cycles - the former specifically includes the processes associated with psychopathology according to ACT (e.g., fusion) - or, after some ACT (it is hoped), the Acceptance and Commitment cycles.

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I got a bit of feedback regarding these diagrams from my ACT follow-up group today. The view seemed to be that the 4x4 diagram provides a quicker reminder of the central ACT messages, that might be more useful in times of trouble, whereas the Four Cycles looks more complicated, but might have a role when learning ACT in more relaxed contexts. On the issue of using "noticing" to represent "self-as-context" and "being present", my group felt that "noticing" has the helpful connotation of something that is readily accessible in everyday life, whereas accessing an observer self seemed to suggest something more formal and effortful - perhaps less natural in everyday life. However, it was also said that being introduced to living in the present and the observer-self separately might be better when first learning ACT, moving to the more accessible noticing concept later.

Finally, I must mention that conversations with Mark Webster have influenced the development of these diagrams, and I believe that he in turn has been influenced by the Life Manual approach of Kevin Polk and colleagues.

David

Comparing ACT and CBT

From my website, www.whitepinepsych.com:

Treatment Approaches

Cognitive-Behavioral Therapy
What is Cognitive-Behavioral Therapy (CBT)? The history of CBT dates back to the seminal work of B.F. Skinner, the father of modern behavior therapy. At that time, behavior therapy was a reaction to the traditional Freudian forms of psychotherapy that were only loosely based on scientific principles and were difficult to subject to rigorous scientific study. Skinner held psychology accountable as a science of human behavior, forever changing the face of psychotherapy. Techniques drawn from Skinner's basic behavioral science continue to be employed with good effect in modern psychotherapy. Skinner's account, however, had its limitations. The most notable limitation was that his account of human language and cognition failed to generate a vigorous line of basic research, limiting its evolution to forms that could be employed with patients with complicated psychological problems. Instead, the field opened to the work of Albert Ellis and Aaron T. Beck, the founders of modern cognitive therapy. Ellis and Beck, and their many successors, transformed the practice of psychotherapy by emphasizing therapy techniques that aimed to change the content and manner of one's thinking, not just their overt behavior. Cognitive therapy and behavior therapy continued to cross-fertilize each other over the past several decades. Modern CBT incorporates both cognitive and behavioral techniques. CBT has become the most well-known, mainstream approach to therapy, partly because it has, by far, the strongest research support for its effectiveness in treating a wide range of emotional and behavioral problems. CBT has been found effective in treating depression, anxiety disorders, the effects of trauma, substance abuse and addiction, complications related to medical conditions, and many other conditions.

Acceptance and Commitment Therapy
What is Acceptance and Commitment Therapy (ACT, said as the word "act")? ACT, just celebrating its 25th anniversary since its inception, is an innovative form of behavior therapy that has built upon both the strengths and the weaknesses of modern cognitive-behavioral therapy (CBT). ACT is based on a behavioral account of human language and cognition called Relational Frame Theory (RFT), which has "filled in the holes" left by Skinner's theories. RFT, in contrast to Skinner's accounts, has generated a vigorous body of basic research into human language and cognition, providing fuel for the development of new treatment approaches. The "fruit" of this progress can be found in the philosophy and basic concepts underlying ACT. ACT has moved away from the traditional CBT emphasis on changing or correcting one's thoughts in order to alleviate suffering. Instead, ACT aims to alter the functions of our private experiences (thoughts, feelings, memories, bodily reactions), so they no longer entangle us. Said another way, ACT aims to change our relationship with these private events so we can become free from their grip, and free from the patterns that bind us and prevent us from living a flexible, meaningful, and enjoyable life. In the service of these aims, ACT incorporates acceptance strategies, mindfulness techniques, and a wide range of behavioral approaches already known to be effective from CBT.

Metaphors

Here are some metaphors that can be used when introducing ACT to clients.

The Hexaflex Dimensional Approach to Diagnostics

from

Wilson, K. G. (2006). The Heart of Acceptance and Commitment Therapy.

Wilson, K. G. (May, 2007) The hexaflex diagnostic: A fully dimensional approach to assessment, treatment, and case conceptualization. Presidential address presented at the annual convention of the Association for Contextual Behavioral Science, Houston, TX.

Empirical clinical psychology has largely been focused on measurement of the frequency and severity of various signs and symptoms and the treatment of psychological syndromes defined by clusters of signs and symptoms (DSM disorders for the most part). These syndromes have increasingly organized clinical psychology in spite of much criticism. It is imperative for us to understand that this is not as trivial as would be yet another theory of psychopathology. In such an instance, the presence of the theory might organize the activities of a relatively small group of individuals who share the area of research interest. Supposedly atheoretical syndromal classification, as seen in the DSM, has had a much more far reaching impact. Our central federal funding agency, the National Institutes of Mental Health, is organized around these categories, as are our abnormal psychology textbooks, journals, assessment instruments, and reimbursement for professional services. Such hegemony is wholly unwarranted based upon available evidence. Concerns about syndromal classification of psychological problems has been around for a good long time. However, only recently has dawn begun to break within the DSM effort.

The failure of syndromal classification carries with it a call for alternatives. At the University of Mississippi Center for Contextual Psychology and Acceptance and Commitment Therapy Treatment Development Group, we are exploring an alternative approach. Based on the idea that multiple systems of classification ought to compete with the gold standard being the treatment utility of the system of problem classification, we are currently pursuing the development and testing of the hexaflex model as the kernel of a fully dimensional diagnostic system within which there exists close linkage between diagnosis, assessment, and intervention.

Posted below are 1) slides from the plenary session in which the Hexaflex Diagnostic was presented at the ACT Summer Institute and 2) draft versions of clinician worksheets designed to facilitate use of the hexaflex model in this way. Please feel free to offer any feedback you might have as to the utility of the model and tools presented here. Send feedback to Kelly Wilson at kwilson@olemiss.edu These documents are extracted from a book in progress "The Heart of ACT," please copy and use at will for clinical practice and research. Distribute only with express consent of the author.

peace all,
Kelly

ACT ADVISOR Psychological Flexibility Measure

Please find attached a hexaflex-based self-report measure, and a form for recording scores on charts if the measure is used repeatedly. ACT ADVISOR (you guessed it) is an acronym for the hexaflex processes (Acceptance; Commitment & Taking action; Attention to present; Defusion; Values Identification; Self as Observer; and Resulting psychological flexibility). It is hoped that the instrument may be useful both in case formulation and in tracking progress during therapy.

The idea for using the hexaflex as a diagnostic/ case formulation tool was, I believe, originally Kelly's and his materials (see The Hexaflex Dimensional Approach to Diagnostics) influenced the development of this instrument. Steve made helpful suggestions about the anchor statements for each process in earlier drafts, and I am also grateful for the ACT listserv community’s interest and input.

ACT Case Formulation Framework

I. Context for case formulation

The goal of ACT is to help clients consistently choose to act effectively (concrete behaviors in alignment with their values) in the presence of difficult or interfering private events.

II. Assessment and Treatment Decision Tree

Beginning with the target problem, as specified by the client or significant others, refine these complaints and concerns into functional response classes that are sensitive to an ACT formulation and to the client's contextual circumstances, and link treatment components to that analysis

A. Consider general behavioral themes and patterns, client history, current life context, and in session behavior that might bear on the functional interpretation of specific targets in ACT terms. These may include:

1. General level of experiential avoidance (core unacceptable emotions, thoughts, memories, etc.; what are the consequences of having such experiences that the client is unwilling to risk)
2. Level of overt behavioral avoidance displayed (what parts of life has the client dropped out of)

3. Level of internally based emotional control strategies (i.e., negative distraction, negative self instruction, excessive self monitoring, dissociation, etc)
4. Level of external emotional control strategies (drinking, drug taking, smoking, self-mutilation, etc.)
5. Loss of life direction (general lack of values; areas of life the patient "checked out" of such as marriage, family, self care, spiritual)
6. Fusion with evaluating thoughts and conceptual categories (domination of "right and wrong" even when that is harmful; high levels of reason-giving; unusual importance of "understanding," etc.)

B. Consider the possible functions of these targets and their treatment implications.

1. Is this target linked to specific application of the tendencies listed under "A" above
2. If so, what are the specific content domains and dimensions of avoided private events, feared consequences of experiencing avoided private events, fused thoughts, reasons and explanations, and feared consequences of defusing from literally held thoughts or rules

3. If so, in what other behavioral domains are these same functions seen?
4. Are there other, more direct, functions that are also involved (e.g., social support, financial consequences)
5. Given the functions that are identified, what are the relative potential contributions of:

a. generating creative hopelessness (client still resistant to unworkable nature of change agenda)

b. understanding that excessive attempts at control are the problem (client does not understand experientially the paradoxical effects of control)
c. experiential contact with the non-toxic nature of private events through acceptance and exposure (client is unable to separate self from reactions, memories, unpleasant thoughts)
d. developing willingness (client is afraid to change behavior because of beliefs about the consequences of facing feared events)
e. engaging in committed action based in values (client has no substantial life plan and needs help to rediscover a value based way of living)

C. Consider the factors that may be perpetuating the use of unworkable change strategies and their treatment implications

1. Client's history of rule following and being right(if this is an issue, consider confronting reason giving through defusion strategies; pit being right versus cost to vitality; consider need for self-as-context and mindfulness work to reduce attachment to a conceptualized self)
2. Level of conviction in the ultimate workability of such strategies

(if this is an issue, consider the need to undermine the improperly targeted change agenda, i.e., creative hopelessness)
3. Belief that change is not possible(if this is an issue, consider defusion strategies; revisit cost of not trying; arrange behavioral experiments)4. Fear of the consequence of change(if this is an issue, consider acceptance, exposure, defusion)

5. Short term effect of ultimately unworkable change strategies is positive(if this is an issue, consider values work)

D. Consider general client strengths and weaknesses, and current client context

1. Social, financial, and vocational resources available to mobilize in treatment

2. Life skills (if this is an issue, consider those that may need to be addressed through first order change efforts such as relaxation, social skills, time management, personal problem solving)

E. Consider motivation to change and factors that might negatively impact it

1. The "cost" of target behaviors in terms of daily functioning (if this is low or not properly contacted, consider paradox, exposure, evocative exercises before work that assume significant personal motivation)

2. Experience in the unworkability of improperly focused change efforts (if this is low, move directly to diary assessment of the workability of struggle, to experiments designed to test that, or if this does not work, to referral)
3. Clarity and importance of valued ends that are not being achieved due to functional target behavior, and their place in the client's larger set of values (if this is low, as it often is, consider values clarification. If it is necessary to the process of treatment itself, consider putting values clarification earlier in the treatment).
4. Strength and importance of therapeutic relationship (if not positive, attempt to develop, e.g., through use of self disclosure; if positive, consider integrating ACT change steps with direct support and feedback in session)

F. Consider positive behavior change factors

1. Level of insight and recognition (if insight is facilitative, move through or over early stages to more experiential stages; if it is not facilitative, consider confronting reason giving through defusion strategies; pit being right versus cost to vitality; consider need for self-as-context and mindfulness work to reduce attachment to a conceptualized self)
2. Past experience in solving similar problems (if they are positive and safe from an ACT perspective, consider moving directly to change efforts that are overtly modeled after previous successes)
3. Previous exposure to mindfulness/spirituality concepts (if they are positive and safe from an ACT perspective, consider linking these experiences to change efforts; if they are weak or unsafe - such as confusing spirituality with dogma - consider building self-as-context and mindfulness skills)

III. Building interventions into life change and transformation strategy

A. Set specific goals in accord with general values
B. Take actions and contact barriers
C. Dissolve barriers through acceptance and defusion
D. Repeat and generalize in various domains

(Originally posted by Steve Hayes and moved to this location by J. Luoma)

The actView (the board for The ACT Game)

Attached is the actView. It is a simple tool for doing ACT Case Conceptualizations. You can use it to do case conceptualizations based on intake material, or you can use it after sessions as a supervision tool.

The actView is also used as a "board" for The ACT Game. A group of trainees can play at sending a client communication into the Therapy Context, observing where the communication lands in terms of stuck in Let Go, Show Up or Get Moving (or flexible in Valued Living with Less Struggling), then having a Therapist communicate an intervention designed to influence the client toward Valued Living with Less Struggling or reinforce flexibility in Valued Living with Less Struggling.

Facing the Current Situation ("Creative Hopelessness")/Control is a Problem

Purpose: To notice that there is a change agenda in place and notice the basic unworkability of that system; to name the system as inappropriately applied control strategies; to examine why this does not work

Method: Draw out what things the client has tried to make things better, examine whether or not they have truly worked in the client’s experience, and create space for something new to happen.

When to use: As a precursor to the rest of the work in order for new responses to emerge, especially when the client is really struggling. You can skip this step in some cases, however.

Things to avoid: Never try to convince the client: their experience is the absolute arbiter. The goal is not a feeling state, it is what the Zen tradition calls “being cornered.”

Examples of techniques designed to increase creative hopelessness:

These clinical materials were assembled by Elizabeth Gifford, Steve Hayes, and Kirk Stroshal

Cognitive Defusion (Deliteralization)

Purpose: See thoughts as what they are, not as what they say they are.

Method: Expand attention to thinking and experiencing as an ongoing behavioral process, not a causal, ontological result

When to use: When private events are functioning as barriers due to FEAR (fusion, evaluation, avoidance, reasons)

Examples of defusion techniques

These clinical materials were assembled by Elizabeth Gifford, Steve Hayes, and Kirk Stroshal

Acceptance

Purpose: Allow yourself to have whatever inner experiences
are present when doing so foster effective action.

Method: Reinforce approach responses to previously aversive inner experiences, reducing motivation to behave avoidantly (altering negatively reinforced avoidant patterns).

When to use: When escape and avoidance of private events prevents positive action

Examples of acceptance techniques

These clinical materials were assembled by Elizabeth Gifford, Steve Hayes, and Kirk Stroshal

Self as Context

Purpose: Make contact with a sense of self that is a safe and consistent perspective from which to observe and accept all changing inner experiences.

Method: Mindfulness and noticing the continuity of consciousness

When to use: When the person needs a solid foundation in order to be able to experience experiences; when identifying with a conceptualized self

Examples of techniques designed to increase self as context

These clinical materials were assembled by Elizabeth Gifford, Steve Hayes, and Kirk Stroshal

Valuing as a Choice

Purpose: To clarify what the client values for its own sake: what gives your life meaning?

General Method: To distinguish choices from reasoned actions; to understand the distinction between a value and a goal; to help clients choose and declare their values and to set behavioral tasks linked to these values

When to use: Whenever motivation is at issue; again after defusion and acceptance removed avoidance as a compass

Examples of values techniques

These clinical materials were assembled by Elizabeth Gifford, Steve Hayes, and Kirk Stroshal

At-Risk Adolescents

Experimental tests to date:

None Published

For further information contact: Amy Murrell (amurrell@unt.edu) or Kelly Wilson (kwilson@olemiss.edu), University of Mississippi.

Author's note: We are posting this protocol in the hope that they will provide useful information in helping clients and spark further interest and research in ACT with children and adolescents. Please, recognize that we consider the treatment technology to be evolving in nature. These protocols, therefore, should be viewed as works in progress. The underlying principles should be adhered to, but the protocols can (and indeed should) be used with flexibility.

Agoraphobia

An ACT protocol designed for use with agoraphobia.

Experimental tests to date:

Hayes, S. C., Wilson, K. G., Afari, N., & McCurry, S. (November 1990). The use of Acceptance and Commitment therapy in the treatment of agoraphobia. Paper presented at meeting of the Association for the Advancement of Behavior Therapy, San Francisco.

This is a very early anxiety protocol, written about 18 years ago. There has been a lot of work since on ACT for anxiety and though it is still recognizably the same kind of protocol, it has gotten better as we've gone along. For an excellent and detailed ACT anxiety protocol see the book by Eifert and Forsyth, 2005. Acceptance and Commitment Therapy for anxiety disorders. Oakland: New Harbinger.

For further information contact: Steve Hayes (hayes@unr.edu), Department of Psychology, University of Nevada, Reno, NV 89557-0062.

Acceptance and Commitment Training for Substance Abuse Counselors

Acceptance and Commitment Training for Substance Abuse Counselors protocol.

Experimental tests to date:
Varra, A. A., Hayes, S. C., Roget, N., & Fisher, G. (in press). Using Acceptance and Commitment Training to Increase the Effectiveness of Continuing Education in Pharmacotherapy for Substance Use. Journal of Consulting and Clinical Psychology.

ACT Made Simple: Togus One Week Protocol

Attached is a more developed version of the Togus one-week protocol. Kevin Polk presented the sketch of this at ACT SI III. Dr. Hambright has developed it further. Email Kevin if you have questions. polkkev@gmail.com.

Click here for the newest version of the protocol

Additional materials are routinely updated on Kevin Polk's blog

ACT Treatment Outlines for Anxiety and Depression (Forman et al., 2007 effectiveness study)

This page includes treatment outlines that were used in the Forman and colleagues (2007) effectiveness study comparing ACT and CT for anxiety and depression.

Experimental tests to date:
Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. D., & Geller, P. A. (2007). A randomized controlled effectiveness trial of Acceptance and Commitment Therapy and Cognitive Therapy for anxiety and depression. Behavior Modification, 31(6), 772-799.

ACT With Couples

This is not actaully a protocol as such, but this page seemed like the most logical place on the website to locate it. It is a powerpoint presentation from a half-day workshop I have given a few times, on the use of ACT with couples. I have a book on this coming out in early 2009 (called 'ACT With Love' - published by New Harbinger) The link below allows you to download it from my website: www.actmindfully.com.au

http://www.actmindfully.com.au/upimages/ACT_with_Couples_-_Russ_Harris.ppt

Developmentally Disabled and Psychotic Individuals

Authors note: The co-morbidity of psychosis in individuals with developmental disabilities may exacerbate the financial strain, emotional turmoil, and difficulties in adaptive functioning that these individuals experience. Given the salience of distress across domains of functioning, there exists a pressing need for more effective interventions to address this population. I am posting this protocol in the hope that it will assist treatment practitioners working with the developmentally disabled. It is an attempt to create more "physicalized" ACT metaphors for clients who think more concretely. Please understand that ACT work with this population is evolving and that this protocol is a work in progress. An small single case study using this protocol was discussed in Pankey and Hayes, 2003. (see publications list).

Diabetes Management

The ACT for diabetes management protocol is available in book form in

Gregg, J., Callaghan, G., & Hayes, S. C. (2007). The diabetes lifestyle book: Facing your fears and making changes for a long and healthy life. Oakland, CA: New Harbinger.

Experimental tests to date:
Gregg, J. A., Callaghan, G. M., Hayes, S. C., & Glenn-Lawson, J. L. (2007). Improving diabetes self-management through acceptance, mindfulness, and values: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 75(2) , 336–343.

Epilepsy

Attached is the dissertation by Lundgren (2004) that includes the ACT for epilepsy treatment protocol.

Experimental tests to date:

Lundgren, T. (2004). Psychological treatment of epilepsy. Unpublished dissertation, Uppsala University, Uppsala, Sweden.

Lundgren, A. T., Dahl, J., Melin, L., & Kies, B. (2006). Evaluation of Acceptance and
Commitment Therapy for drug refractory epilepsy: A randomized controlled trial in South Africa. Epilepsia, 47, 2173-2179.

Lundgren, T., Dahl, J., & Hayes, S. C. (in press). Evaluation of mediators of change in the
treatment of epilepsy with Acceptance and Commitment Therapy. Journal of Behavioral Medicine

Group Treatment of Depression

Experimental tests to date:

Zettle, R. D., & Hayes, S. C. (1986). Dysfunctional control by client verbal behavior: The context of reason giving. The Analysis of Verbal Behavior, 4, 30-38.

Zettle, R. D., & Hayes, S. C. (1987). A component and process analysis of cognitive therapy. Psychological Reports, 61, 939-953.

Zettle, R. D., & Raines, J. C. (1989). Group cognitive and contextual therapies in treatment of depression. Journal of Clinical Psychology, 45, 438-445.

For further information contact: Robert Zettle (zettle@wichita.edu), Wichita State University, Department of Psychology, 1845 N. Fairmount, Wichita, KS 67260-0034

H.E.A.T. (Honorably Experiencing Anger and Threat) Protocol

Select this link to access the HEAT (Honorably Experiencing Anger and Threat) group treatment protocol developed by Andy Santanello and Sharon Kelly.

Helping Psychotic Patients Cope with Positive Psychotic Symptoms

Experimental tests to date:

Bach, P., & Hayes, S. C. (2002). The use of Acceptance and Commitment Therapy to prevent the rehospitalization of psychotic patients: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 70(5), 1129-1139.

For further information contact: Patty Bach (pattybach@earthlink.net), Department of Psychology, Illinois Institute of Technology, 3300 South Federal Street, Chicago, IL 60616

Math Anxiety

Below is the ACT for math anxiety protocol developed by Zettle (2003).

Experimental tests to date:
Zettle, R. D. (2003). Acceptance and commitment therapy (ACT) vs. systematic desensitization
in the treatment of mathematics anxiety. The Psychological Record, 53, 197–215.

OCD

An eight session ACT for OCD protocol.

Experimental tests to date:

Twohig, M. P., Hayes, S. C., & Masuda, A. (2006). Increasing willingness to experience obsessions: Acceptance and Commitment Therapy as a treatment for obsessive compulsive disorder. Behavior Therapy, 37(1), 3-13.

For further information contact: Mike Twohig (twohigm@unr.nevada.edu), Department of Psychology, University of Nevada, Reno, NV 89557-0062.

Postpartum Depression

An ACT protocol designed for use with postpartum depression.

Experimental tests to date:

None

For further information contact: Espen Klausen (eklausen@hotmail.com), M. S., Department of Psychology, University of Wisconsin-Milwaukee.

Psychotherapy for methamphetamine dependence

An individual outpatient psychotherapy protocol for use with methamphetamine dependence. It combines motivational interviewing techniques and cognitive therapy relapse prevention techniques within an ACT framework.

Severe Substance Abuse Problems

An Individual ACT protocol designed for use in severe substance abuse problems.

Experimental tests to date:

Hayes, S. C., Wilson, K. G., Gifford, E. V., Bissett, R., Piasecki, M., Batten, S. V., Byrd, M., & Gregg, J. (2004). A randomized controlled trial of twelve-step facilitation and acceptance and commitment therapy with polysubstance abusing methadone maintained opiate addicts. Behavior Therapy, 35, 667-688.

Skin picking

The treatment protocol for the ACT for skin picking study is exactly the same as the one for the OCD study by the same authors. All you need to do is change the word "obsession" to "urge to pick" and it will fit nicely.

Twohig, M. P., Hayes, S. C., & Masuda, A. (in press). A preliminary investigation of ACT for chronic skin picking. Behaviour Research and Therapy.

Stigma Toward People With Psychological Disorders

Below is a protocol for a two and a half hour workshop on ACT for stigma toward people with psychological disorders developed by Akihiko Masuda, Kara Bunting and Steven Hayes. The psychoeducation control protocol used in Masuda et al. (2007) is also included.

Experimental tests to date:
Masuda, A., Hayes, S. C., Fletcher, L. B., Seignourel, P. J., Bunting, K., Herbst, S. A., Twohig, M. P., & Lillis, J. (2007). The impact of Acceptance and Commitment Therapy versus education on stigma toward people with psychological disorders. Behaviour Research and Therapy, 45(11), 2764-2772.

Trichotillomania

The protocol is available in book form in

Woods, D.W. & Twohig, M.P. (2008). Trichotillomania: An ACT-enhanced Behavior Therapy Approach Therapist Guide. Oxford University Press.

The accompanying client workbook is available in

Woods, D.W. & Twohig, M.P. (2008). Trichotillomania: An ACT-enhanced Behavior Therapy Approach Workbook. Oxford University Press.

Experimental tests to date:
Woods, D. W., Wetterneck, C. T., & Flessner, C. A. (2006). A controlled evaluation of Acceptance and Commitment Therapy plus habit reversal for trichotillomania. Behaviour Research and Therapy, 44, 639-656.

Weight Maintenance

Below is a protocol for a 1-day workshop for weight-related stigma and weight maintenance based on Acceptance and Commitment Therapy developed by Jason Lillis, Steven Hayes, and Kara Bunting.

Worksite Stigma and Burnout

This is a protocol designed to reduce entanglement with stigmatizing thoughts about clients and through that reduction in burnout and stress at work.

Experimental tests:

Hayes, S. C., Bissett, R., Roget, N., Padilla, M., Kohlenberg, B. S., Fisher, G., Masuda, A., Pistorello, J., Rye, A. K., Berry, K. & Niccolls, R. (2004). The impact of acceptance and commitment training and multicultural training on the stigmatizing attitudes and professional burnout of substance abuse counselors. Behavior Therapy, 35, 821-835.

The protcol is for a 6 hour group workshop. It is not very detailed -- refering in a single line to exercises that might take 40 minutes. For those familiar with experiential ACT workshops, this should be enough. You will see most of these exercises at major ACT / RFT conventions such as the World Conferences or the Summer Institutes.

This protocol is currently being revised for a large new grant (which will run from 2005 to 2008) that will replicate and extend the study above. It is our sense that we can do better than the protocol that is here, so don't feel bound by it. Use it as a starting point.

The adherence manual include both ACT and Multicultural Training items since that was the comparision in the study (and in this new grant ... which will include an ACT and MT combination group as well as ACT alone and MT alone and a control).

For more information contact Steve Hayes (hayes@unr.edu), Department of Psychology, University of Nevada, Reno, NV 89557-0062

Worksite Stress Interventions

Experimental tests to date:

Bond, F. W., & Bunce, D. (2000). Mediators of change in emotion-focused and problem-focused worksite stress management interventions. Journal of Occupational Health Psychology, 5, 156-163.

The protocol itself can be found in Bond, F., & Hayes, S. C. (2002). ACT at work. In F. Bond & W. Dryden (Eds.), Handbook of Brief Cognitive Behaviour Therapy (pp. 117-140). Chichester, England: Wiley.

For further information contact: Frank Bond (f.bond@gold.ac.uk), Department of Psychology, Goldsmiths College, University of London, New Cross, London SE14 6NW

Young Children

Experimental tests to date:

None Published

For further information contact: Amy Murrell (amurrell@unt.edu) or Kelly Wilson (kwilson@olemiss.edu), University of Mississippi.

Author's note: We are posting this protocol in the hope that they will provide useful information in helping clients and spark further interest and research in ACT with children and adolescents. Please, recognize that we consider the treatment technology to be evolving in nature. These protocols, therefore, should be viewed as works in progress. The underlying principles should be adhered to, but the protocols can (and indeed should) be used with flexibility.

Defusion Exercises

Metaphors

The purpose of this section is to allow members to share new ACT-relevant metaphors that have come out of their therapeutic or accademic work. If adding a metaphor (by adding a child page), please say something about it. For example, how it might be used or what ACT-relevant points it might be trying to make.

Tin Can Monster exercise -- Audio files

Attached is the Tin-Can Monster exercise, which I recorded using the script from GOOYMAIYL. This is a really powerful willingness/acceptance exercise.

I recorded separate tracks for each experiential domain (bodily sensations, emotions, behavioral predispositions, thoughts, memories). This enables clients to repeat tracks to cycle through as many experiences in a domain as they'd like before going on to the next domain. To go through the whole exercise just once takes a fairly long time (45 min) but people can do this acceptance work in smaller chunks over time.

To download the tracks, you must first LOGIN to the site & then when you click on the link & the dialog box appears, click "SAVE" not "play."

Values Exercises

Exercises related to clarifying values and promoting valued actions.

ACT Related Illustrations

The content of the illustrations are as follows:

(A) Illustrates some of the problems engendered by control/avoidance/non-acceptance

(B) Compares and contrasts the medical model vs. the ACT model of psychopathology (including the importance of distinguishing means vs. ends in psychotherapy)

(C) A chart containing multiple examples comparing the behaviorist model vs. cognitive model of causation (i.e., do thoughts really cause behaviors?)

(D) A visual depiction of cognitive defusion

(E) Some illustrations that speak to the approach-avoidance conflict associated with willingness

Hexagon Models

This is a hexaflex (Hexagon Model of Psychological Flexibility) image that I generated in Word based on the image found in the Practical Guide. It took FOREVER, so I figured it might be worth posting. It IS modifiable if you right or control click and "Ungroup" into the shapes and text boxes I used to make it. Hope this is useful to someone!

--- note added later by Steve Hayes: I've also posted two images that can be placed into documents. One is the Hexaflex model, and a related model of psychopathology. These are MS office "png" images but are not modifiable (the originals are in CorelDraw).

By the way, we deliberately placed these Hexaflex images in multiple places -- including the list serve -- so that no copyright would be enforcable on them by publishers. If you need a citation, however, an easy one is

Hayes, S. C., Luoma, J., Bond, F., Masuda, A., and Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes, and outcomes. Behaviour Research and Therapy, 44, 1-25.

ACT Onscreen: Films for Clients

This section of Contextualpsychology.org is for practitioners looking for a film to prescribe to their clients. Along the lines of the suggestions made in Rent Two Films and Let's Talk in the Morning, by John and Jan Hesley or "The Motion Picture Prescription: Watch This Movie & Call Me in the Morning - 200 Movies to Help You Heal Life's Problems", by Gary Solomon. I've found many films contain moments or plot turns that are highly suitable as metaphors for ACT processes. I invite the ACT community to contribute to this resource so we can help our clients and learn from each other.

Here's Jason Luoma's suggested ratings format and modifications to my original proposal. Thanks Jason! 

 At a recent lab retreat, Steve's lab came up with the idea of each movie receiving a hexaflex point rating. This similar to the 0, 1, or 2 two thumbs up from Ebert and Roper, but instead goes from 1 to 6, depending upon the number of ACT processes illustrated. The ultimate prize goes the person who can come up with a movie that illustrates all six ACT processes. Will YOU take up the challenge? It can come from multiple scenes in one movie. The ultimate challenge would be to identify one scene that illustrates all six processes. Go fot it!

I'd suggest when you review a movie, at the start you give it a hexaflex rating according to how many processes the movie illustrates.

The six processes are:

1. Contact with the present moment
2. Acceptance
3. Defusion
4. Self-as-context
5. Values
6. Commitment

For example, a movie that illustrates four of these proceses would get four hexaflex points! So as a format for ratings, I'd suggest the following:

1. Film name
2. Number of Hexaflex Points
3. Character, moment or plot point
4. ACT principle illustrated and which processes it involves.

Also you might want to put the number of hexaflex points in the title section.

Julian: Here's an example (one of my favorites ;-)):

1. The Matrix
2. 1 Hexaflex point (but see Camilla's additional point below)
3. Neo, the Keanu Reeves character, is asked to choose between the red pill or the blue pill
4. Choosing and Willingness - sometimes you can't know the outcome before you choose. Are you willing to have the consequences of choosing and just choose?

Here's Jason's example:

1. Indiana Jones and The Last Crusade
2. 3 hexaflex points
3. When Indiana is just about to get to the holy grail, he finds himself stuck at the edge of a seemingly bottomless chasm. He reads a riddle that suggests that the only way to get across the chasm is to take a leap of faith. So he steps out into mid air, seemingly to fall to his death. Instead, he finds that there is actually a hidden bridge that was built to blend seemlessly into the backdrop of the chasm and his step lands on terra firma. Whew!
4. The scene illustrates committed action, in that Indiana takes a step towards his quest even when unsure of the outcome. It illustrates willingness/acceptance in that the move is leadp of faith, requiring him to make room for his fear. And it illustrates defusion in that while his mind tells him he is going to fall to his death, he is willing to suspend that judgment, and when he actually steps out into a seeming void, he finds that this was an illusion.

To contribute your film, click on add child page below. In the Body section of the Edit page, you type this at the beginning: <ol> <li>My Film</li><li>Number of Hexaflex points</li> <li>The part where the character says something</li> <li>ACT Principle: What's it all about Alfie?</li> </ol>

 Which ends up looking like this:

1. My Film
2. Number of Hexaflex points
3. The part where the character says something
4. ACT Principle: What's it all about Alfie?