SESSION 1
Your life is a sacred journey. And it is about change, growth, discovery, movement, transformation, continuously expanding your vision of what is possible, stretching your soul, learning to see clearly and deeply, listening to your intuition, taking courageous challenges at every step along the way. You are on the path … exactly where you are meant to be right now… And from here, you can only go forward, shaping your life story into a magnificent tale of triumph, of healing, of courage, of beauty, of wisdom, of power, of dignity, and of love.
—Caroline Adams
Goals and Theme
Session 1 has four goals: (1) to establish good rapport with clients; (2) to provide clients with a general understanding about the nature and function of anxiety; (3) to introduce clients to the active, experiential, and participatory nature of this treatment; and (4) to gently introduce value-driven action in real life as the primary treatment goal, while being sensitive to the goals of clients which, at this stage, probably still focus on anxiety reduction and symptom control.
This first session is designed to lay the groundwork for what will come. A good portion of it is devoted to developing rapport and dispelling common misconceptions about fear, anxiety, and psychotherapy more generally (e.g., anxiety is bad, psychotherapy is about fixing symptoms). Anxiety and fear are adaptive in many circumstances, and they need not be monsters. They are part of the totality of human experience and only become monsters, and hence disordered, when we act to avoid and escape from them. It follows that the goal of this treatment is about living a rich and meaningful life, fully and without defense.
Therapy is framed as an opportunity to learn and practice new and more flexible ways of responding when experiencing anxiety. The basic idea is for clients to learn ways of no longer letting anxiety be an obstacle to doing what they want to do. Accordingly, the therapist commits to making treatment all about what clients really care about and what matters most in clients’ lives—it is about helping clients accept what needs to be accepted and change what can be changed to make meaningful changes and life improvements.
SESSION OUTLINE
1. _Introductory Information (5 min.)
2. _Initial Problem Discussion (5 min.)
Ratings of Distress and Disablement form
3. _Nature and Function of Normal Fear and Anxiety (15 min.)
o What Are Fear and Anxiety?
o What Is the Purpose of Anxiety—Is It Good for Anything?
o Are Anxiety and Fear Dangerous?
o How Pervasive Are Problems with Anxiety and Fear?
4. _How Has Anxiety Become a Problem in the Client’s Life? (10 min.)
5. _Treatment Focus/Goal and Therapist Commitment (10 min.)
6. _Acquisition of New Skills Through Direct Experience (5 min.)
7. _Centering Exercise (5 min.)
8. _Rationale for Experiential Life Enhancement Exercises (5 min.)
o Experiential Monitoring Forms
9. _Session Materials and Handouts
o Ratings of Distress and Disablement form
o Living in Full Experience (LIFE) form
o Daily ACT Ratings form
AGENDA
1. INTRODUCTORY INFORMATION (5 MIN.)
Spend a few moments with general introductions and procedures, covering the following issues:
§ Initial discomfort is natural and usually subsides as the client becomes familiar with the process of therapy.
§ All information will be kept confidential, although you are obligated to inform when a client poses a danger to self or others; also indicate whether sessions will be audio- and videotaped for purposes of supervision and training.
§ Provide client with twenty-four-hour emergency numbers.
2. INITIAL PROBLEM DISCUSSION (5 MIN.)
At this point, the therapist should refer to the information gathered from the client’s initial contact or intake form and ask them what primarily brought them to therapy. Ask clients about the area of fear and anxiety that is currently most distressing and disabling and has been a major concern for at least a month. Ask clients to describe a recent episode of fear or panic attacks, phobic anticipation or worry about events in the future, and avoidance or escape behavior in relation to the episode. Avoid lengthy symptom descriptions or presentations of the history of their disorders.
Discuss each of the main anxiety domains (social phobia, post-traumatic stress disorder, panic disorder/agoraphobia, generalized anxiety disorder, specific phobias, obsessive-compulsive disorder) with your clients using lay descriptions of the major anxiety disorders rather than the DSM labels. Focus on how much they are distressed by each one and how much each one interferes with their life functioning, using the 0 to 8 scale shown below (the form is also available on the enclosed CD). Facilitate client ratings of distress and disablement by prompting them to consider issues such as how much of the day they are preoccupied with a specific set of anxiety problems, how much their daily life is influenced by anxiety problems, how much they are prevented from doing what they want to do because of anxiety, and how frequently they experience acute anxiety and fear in relation to each area of anxiety. Therapists should write the numeric ratings on the form rather than handing it to clients.
3. NATURE AND FUNCTION OF NORMAL FEAR AND ANXIETY (15 MIN.)
The purpose of this section is to help clients understand the nature and function of normal anxiety and what can make anxiety become “disordered.” Therapists should explain to clients that this early part of therapy will be fairly “educational,” meaning that you will be talking and explaining a lot and looking for input from the client as you go along. Below we only summarize the information to be covered in this section. Please refer to chapter 2 for a more detailed account of these topics.
Start by asking the client to describe what fear, or being afraid, is like for them. Here you will be looking for three components that we think of as comprising the emotions fear and anxiety, namely physiological sensations (e.g., heart flutters, sweating, dizziness, blurred vision, shortness of breath, tension), cognitive aspects (or what clients think when they are afraid), and overt behavior (i.e., what clients do during and immediately following an episode of fear or anxiety, such as escape or avoidance). For a more detailed account of this “triple-response mode” view of anxiety, see Eifert and Wilson (1991).
What Are Fear and Anxiety?
Recall that fear is characterized by an abrupt and acute surge of the sympathetic branch of the autonomic nervous system, accompanied by wide-ranging and intense physiological sensations (e.g., increased perspiration, rapid heartbeat, breathlessness, dizziness) and a powerful action tendency to fight or flee from perceived or real environmental and bodily signs of threat or danger (see Barlow, 2002). Fear is a present-oriented mood state that occurs in response to real or imagined danger or threat. In many circumstances, fear is perfectly adaptive because it motivates and mobilizes us to take action. Anxiety, by contrast, is a future-oriented mood state that is accompanied by anxious apprehension, worry, and heightened and sustained activity of the sympathetic nervous system (e.g., increased muscle tension, chest tightness). We are typically anxious about something that may happen in the near or distant future.
Use the client’s descriptions of their fear and anxiety experience to outline the difference between fear and anxiety. Have them take an example of their fear and turn it into anxiety and vice versa. For instance, a panic attack is a good example of fear, whereas worry about a future attack represents anxiety. The response one might experience while recalling a traumatic memory may be close to fear, whereas worry that the memory might resurface again characterizes anxiety. Worry about a house fire is anxiety, whereas being in your home while it is burning to the ground is fear. The reaction to seeing a bear in the woods is fear, whereas worrying about the possibility of seeing a bear in the woods at some later date is anxiety.
What Is the Purpose of Anxiety—Is It Good for Anything?
Most clients with anxiety problems will have a hard time thinking about the purpose of anxiety, let alone answering the question of what it may be good for. After all, anxiety is aversive, and aversive events cause suffering, right? Your client’s own pain and suffering over their anxiety will tell them as much. So they may rightly ask, how could anxiety be good for anything?
Take a moment to explore the practical benefits of anxiety and fear. Ask clients whether they can think of instances in their lives where they or someone close to them experienced fear and this reaction, in turn, helped them stay alive, safe, and out of trouble. Most clients will be able to remember at least one of those situations. If not, you can give one or two examples from your own life. The examples will probably show that fear made them take some type of defensive or offensive action when their health or safety appeared to be threatened. This can help clients discover that responding to real threats with fear, and at times anxiety, allows appropriate action. Both tendencies have worked well for us as individuals and as a species because without such fear-induced actions, we would probably not have survived.
Also, the beneficial effects of moderate amounts of anxiety and worry have been known for a long time (Yerkes & Dodson, 1908). These emotions help motivate us to respond to real and potential threats, and to take action to manage our day-to-day lives (e.g., health, job, future tasks/plans). In this sense, fear and anxiety are motivational. Note also that the three components of fear and anxiety (physical sensations, thinking, and doing) are not unusual or disordered—we feel, think, and do things all the time. It would be hard to imagine living without these three aspects of human experience.
Are Anxiety and Fear Dangerous?
To address the common question of whether anxiety and fear are dangerous, return to the discussion on the adaptive benefits of fear and anxiety. Though the temptation may be great, do not simply reply with no to this question and move on. Remember that most clients have come to view anxiety and fear as dangerous in some way. For this reason, it is important to reiterate that there is nothing disordered about emotions such as anxiety and fear. They are perfectly adaptive and are not dangerous by themselves. We all have the human potential within us to be extremely anxious, fearful, and sad. We also have the potential to be joyous, full of life, and at peace with ourselves and the world we live in.
Anxiety and fear typically become dangerous if we are unwilling to experience them, and thus live in the service of our avoidance of this facet of what it means to be a fully functioning human being. Hence the danger of anxiety and fear is not that we have them or that we have too much of them. Anxiety and fear become dangerous when we let such emotions rule our lives. As a consequence, we fail to live. We compromise what is truly important in our lives. And, we let anxiety and fear come to define who we are and what we are about.
How Pervasive Are Problems with Anxiety and Fear?
Many clients with anxiety disorders feel that they are alone with their problems. Therapists should therefore point out that anxiety disorders are among the most prevalent psychological disorders, affecting as much as 25 percent of the general population at some point in their lifetime (Eaton, Dryman, & Weissman, 1991; Kessler et al., 1994). Inform clients that we typically learn the processes that contribute to such disorders (i.e., avoidance, escape, control tendencies to manage unpleasant emotions) early on in life. For instance, as kids we learn to avoid touching a red-hot stove because it hurts. We may have learned this the hard way or by listening to our parents or caregivers warning us about the consequences.
We are socialized to use physical and psychological pain and suffering as reasonable reasons for our behavior and that of others. For instance, it is acceptable to miss a day at work or school for feeling ill. We also learn to apply the very same management strategies to our thoughts, memories, and emotions that are unpleasant or painful. Yet, those sensible strategies of dealing with the hot stove and other sources of real harm and pain do not work well when applied to our emotions. We cannot avoid feelings of anxiety and fear in the same way that we keep our hands away from the hot stove. Ask clients whether they can turn their emotions on or off in the same way that they can move their hand on or off a hot stove. Ask clients whether they can make themselves feel one way or another just because they want to. Ask clients whether they have noticed that their feelings go with them no matter where they run to. Could it be that we cannot escape or avoid our feelings of anxiety, apprehension, and insecurity because they are simply part of us? Remember, “You can run, but you can’t hide from yourself!”
4. HOW HAS ANXIETY BECOME A PROBLEM IN THE CLIENT’S LIFE? (10 MIN.)
At this point, therapists should bring the discussion to the important question of what can make normal anxiety problematic or disordered. Rather than simply explaining the issue to clients, we suggest letting clients explore how anxiety or fear has become a problem in their own lives. Ask clients to look for one obvious example of how anxiety-related avoidance has become a problem in their lives, and how such avoidance may have narrowed their life space (what they do). Consistent with the model we outlined in chapters 3 to 5, ask clients to evaluate patterns of avoidance that are designed to prevent them from feeling anxious or afraid or to prevent them from thinking about anxious or disturbing thoughts, as well as any action following anxiety and fear that is geared to manage such thoughts and emotions. Below is a short clinical excerpt illustrating avoidance of the possibility of experiencing anxiety and the consequences of such avoidance for the client.
Therapist: Can you tell me about a recent example where you experienced strong feelings of anxiety?
Client: Well, the other day my friends asked me to go out with them to see a new movie. I really wanted to go, but then I got all anxious about being in a dark movie theater with lots of people.
Therapist: So, it sounds like you really love movies and that seeing movies is important for you.
Client: Oh yes, I am sort of a movie buff.
Therapist: I also get this sense that you didn’t end up going out to see the movie. Am I right?
Client: Yup. I told them that I wasn’t feeling well—like a cold. I wasn’t really sick or anything like that, but they bought the story.
Therapist: What did you end up doing that night?
Client: I stayed home alone feeling miserable about myself and why I can’t just be like other, normal people.
Therapist: Hmm … so even though you were not sick, you ended up spending the night feeling “sick.”
Client: [long pause] Yes, this is usually what happens to me.
At some point during such discussions, clients typically say that their biggest problem is that they simply have too much anxiety and that this anxiety is paralyzing them. Therapists should not argue with clients about this (or indeed any other) issue. Instead, you could agree that too much fear or anxiety can indeed impede one’s ability to take productive action. Even animals don’t do much under extreme fear. Yet there is one important difference between humans and animals that has to do with language. Humans, unlike other animals, can get caught up in a struggle with their own emotions in an effort not to have them. This creates a whole set of additional problems that animals do not have because they are not verbal beings.
This struggle takes much effort, and effort directed at struggling to minimize or prevent anxiety and fear is effort not invested in other valued life activities. Humans end up avoiding people, places, activities, and situations that might lead to anxious and fearful feelings. They may even use and come to rely on substances to minimize the occurrence of such feelings. Humans also will escape from situations during unpleasant emotional states. Thus, when humans quite literally live a life focused on trying not to have anxiety and fear—the unwanted bodily sensations, thoughts, past memories, and worries about the future—we begin to talk about the shift from normal anxiety and fear to disordered anxiety and fear.
This may also be an opportune time to let your client know that there are many people out there who regularly experience panic attacks or high levels of anxiety in various settings but who do not develop panic or another anxiety disorder. Studies have found that these people do not get caught up in a struggle with their anxiety. They also do not devote increasingly larger portions of their life energy and space to the task of avoiding or getting rid of anxiety. They have learned to let their anxiety be and continue to live their lives and do what is really important to them.
At this point, therapists need not delve any further into these issues. The focus of this discussion should simply be on what the client is doing to manage anxiety and fear, and as a consequence what they are not doing by way of living fully and consistently with what they truly care about in their life. In Sessions 2 and 3, there will be time to examine in greater detail additional examples of how efforts to control anxiety have worked and what effect they have had on the client’s life, including more subtle patterns of avoidance and escape. This analysis serves as a stepping-stone to explore alternative ways of dealing with anxiety by letting go of the agenda that anxiety needs to be dealt with, that symptoms need to be gotten rid of, or that there is a quick solution or cure.
5. TREATMENT FOCUS/GOAL AND THERAPIST COMMITMENT (10 MIN.)
At some point in this session, clients will invariably ask, “What about my anxiety? Will it ever go away, or can you at least help me reduce it or control it?” We strongly recommend that therapists do not say things like, “Our goal is not anxiety reduction and symptom control.” Such a statement would almost certainly be inaccurate from the client’s perspective and is not consistent with ACT. At this stage, the client’s goal probably is still anxiety reduction and symptom control, so therapists cannot simply say that anxiety control is not “our” goal. Although you are planting important seeds in this session about how anxiety control efforts have backfired in the client’s life, it is essential that clients have a chance to experience fully the costs and futility of anxiety control and avoidance efforts. This is indeed the very purpose of the numerous experiential exercises in the next few sessions. Simply telling clients what is not your goal could seriously alienate and overwhelm clients at this early stage and result in dropout.
Instead of ruling out anxiety control and reduction—which incidentally may very well occur even if it is not targeted—therapists should frame therapy as an opportunity for clients to learn and practice new and more flexible ways of responding when they experience anxiety. The basic idea is for clients to learn ways of no longer letting anxiety be in the way of doing what they want to do. Using the example of having to practice to learn any new skill (e.g., playing an instrument, playing sports), tell clients that new learning can only occur though experience, not through talking or thinking. Accordingly, you will guide clients through this process of experiencing their fear, worries, and anxiety for what they are rather than what their mind tells them they are. Any questions and discussion about treatment goals is a good opportunity for you as a therapist to state your treatment values and make a commitment to the client right in this first session. For example, “Jane, I want treatment to be all about what you really care about and what matters most in your life. I will do whatever I can to help you accept what needs to be accepted and change what you can change to make improvements and meaningful changes in your life … the place that matters most to you!”
Let clients know that apart from doing exercises in the session, the major component of treatment is for them to engage in activities and exercises at home and elsewhere between sessions. In-session exercises are merely designed to help prepare clients for making important life-enhancing improvements outside of session, where it really counts—in their daily lives! These exercises are focused opportunities for clients to do something different from what they have been doing; namely to face what their mind and body are doing during fear and anxiety in a gradual fashion so as to learn new ways of responding to their own responses. Incidentally, we do not use the term homework because it has negative connotations (i.e., having to do it, usually because someone other than the student or client requests that it be done). Instead, we prefer to refer to such assignments as experiential life enhancement exercises. Point out to clients that such exercises are not arbitrary but will involve activities that are designed to bring them closer to goals that are really important to them. The client is ultimately responsible for making the choice to do such exercises and is more likely to do so if they are perceived as freely chosen and consistent with what matters to them.
Inform clients that treatment is highly experiential and that their success will depend on how much they put into it. This point may require some elaboration, particularly for clients who are unfamiliar with psychotherapy or are seeking solutions where they can take a passive role and be “fixed” by the therapist. Relying on over-the-counter and prescription medications is an example of this passive process. Medications, when taken appropriately, act on our bodies to do what they are designed to do. They require little effort to bring about the desired effects, apart from the act of taking the medication.
Yet there are no medications that can produce a full, rich, and meaningful life. ACT is about changing how clients relate with themselves, including their fears, anxieties, and worries. It is about living better. To get there requires commitment and effort. Indeed, commitment to treatment is critical. Issues will come up that are difficult for your clients. They may even feel a bit worse for a time, before getting better. After all, your clients probably know deep down that things are not working. Otherwise they would not be in the room with you. What you are asking clients to do is choose to give treatment a chance and to suspend their agenda of “getting cured” and getting rid of symptoms. You are not asking clients to will anything. They need only be willing to play the unique deck of cards that life has dealt them (Linehan, 1993).
6. ACQUISITION OF NEW SKILLS THROUGH DIRECT EXPERIENCE (5 MIN.)
This is a tough one for clients to grasp at first, so a few examples will be helpful. One easy example is learning how to ride a bike. Most of us have learned how to ride a bike. How exactly did we do that? Did we learn to ride by hearing someone describe how to ride a bike, watching a video, or reading a book? For most of us, the answer on all three counts would be no. Rather, riding a bike required direct hands-on riding experience on a bicycle, and good riding required many hours of practice and a willingness to fall and get scratched up, bumped, and bruised along the way. And when we fell, we got right back on and tried again. There is no other way to learn how to ride a bike than through such direct experience—and even experienced riders continue to fall once in a while. There are many other examples in life that more or less follow this principle (e.g., learning to hit a baseball, swim, drive a car, be a good parent, teacher, employee, or friend). There is no substitute for direct experience in such cases.
Words alone are no replacement for direct experience with the world. For example, hearing about a beautiful sunset on a windswept beach, with the sounds of birds and the smell and feel of a gentle sea breeze on one’s face is good, but does not compare to the experience of actually being there on the beach at that moment. This, of course, assumes that we are fully present with our direct experiences as they are, even now during therapy. Being present is difficult given the fast-paced lives that many of us lead nowadays. Take, for example, eating a meal while reading or watching the TV, taking a morning shower while thinking about what you will wear and what you have to do that day, driving while talking on a cell phone, and so on. If the goal is eating, experiencing a relaxing shower, or the experience of driving, then do each by itself without doing anything else. Otherwise each activity is diminished because you are not fully present with those events and those events alone.
Tell clients that you would like to start each session with a mindfulness or focusing (“centering”) exercise. The purpose of these exercises is to help them be more ready for new experiences and become better at just noticing what they experience. In this first session, you could finish with such an exercise.
7. CENTERING EXERCISE (5 MIN.)
This little exercise will help clients focus on where they are right now and why they are here. This exercise should take about five minutes to complete. Just like with any other exercise or activity, before you start, ask clients whether they are willing to do it. We suggest that therapists read the instructions to clients in a slow and soft fashion.
1. Go ahead and get in a comfortable position in your chair. Sit upright with your feet flat on the floor, your arms and legs uncrossed, and your hands resting in your lap. Allow your eyes to close gently [pause 10 seconds]. Take a couple of gentle breaths: in … and out—in … and out. Notice the sound and feel of your own breath as you breathe in [pause] and out [pause 10 seconds].
2. Now turn your attention to being inside this room. Notice any sounds that may occur inside the room [pause] and outside [pause 10 seconds]. Notice how you are sitting in your chair [pause 10 seconds]. Focus on the place where your body touches the chair. What are the sensations there? How does it feel to sit where you sit? [pause 10 seconds] Next, notice the places where your body touches itself [pause 10 seconds]. Notice the spot where your hands touch your legs. How do your feet feel in the position that they are in? [pause 10 seconds] What sensations can you notice in the rest of your body? If you feel any sensations in your body, just notice them and acknowledge their presence [pause 10 seconds]. Also notice how they may, by themselves, change or shift from moment to moment. Do not try to change them [pause 10 seconds].
3. Now let yourself be in this room. See if you can feel the investment of you and I in this room—what we are here for [pause 10 seconds]. If you are thinking this sounds weird, just notice that and come back to the sense of integrity in this room. Be aware of the value that you and I are serving by being here [pause 10 seconds]. See if you can allow yourself to be present with what you are afraid of. Notice any doubts, reservations, fears, and worries [pause 10 seconds]. See if you can just notice them, acknowledge their presence, and make some space for them [pause 10 seconds]. You don’t need to make them go away or work on them [pause 10 seconds]. Now see if for just a moment you can be present with your values and commitments. Why are you here? Where do you want to go? What do you want to do? [pause 10 seconds]
4. Then, when you are ready, let go of those thoughts and gradually widen your attention to take in the sounds around you [pause 10 seconds] and slowly open your eyes with the intention to bring this awareness to the present moment and the rest of the day.
8. RATIONALE FOR EXPERIENTIAL LIFE ENHANCEMENT EXERCISES (5 MIN.)
It is useful to initiate some form of self-monitoring between this first session and the next. Self-monitoring serves several functions for both the therapist and client. For the therapist, self-monitoring assignments allow assessment of progress in therapy, and provide a better window on a client’s daily experiences in and within the world outside of therapy. Resulting data can be summarized quantitatively (e.g., via charts, frequencies, means) and more qualitatively for the client. From the client’s perspective, self-monitoring can help make patterns of experiential avoidance and inaction more obvious. Just as we want our clients to show up in therapy, we also want them to show up in their daily lives. Outside the session, self-monitoring and experiential exercises function to promote showing up by increasing contact with patterns of inaction that are getting in the way of valued living and life experiences that are of value to the client. It is, therefore, important to end this first session with a clear rationale for self-monitoring and experiential life enhancement exercises. Both forms introduced at the end of this session are also on the CD and used throughout the entire treatment.
Experiential Monitoring Forms
Living in Full Experience (LIFE). We designed a worksheet—Living in Full Experience (LIFE)—that can be used to monitor and track contexts where anxiety and fear show up, associated experiences (thoughts, physical sensations, and behaviors), client willingness to have those experiences, and how the client’s reactions to them are compromising and interfering with their values and goals. The acronym LIFE is not accidental; it’s a deliberate effort to frame this exercise in terms of what really counts: living. It is best that you go over this form with the client before the end of the session. Ask them to complete this form shortly after every episode where unwanted thoughts, sensations, or feelings occur. Provide enough copies so that multiple daily episodes can be documented. Tell the client that you would like to see their records at the beginning of the next session and those that follow. Ask the client for permission to do so—make it their choice as part of their commitment to therapy.
Daily ACT Ratings. Also ask clients to complete the Daily ACT Ratings form at the end of every day by making a rating on a scale from 0 (not at all) to 10 (extreme amount) of how upset and distressed over anxiety clients were that day, how much effort they put into making anxious feelings or thoughts go away that day, to what degree they would consider that day be part of a vital, workable way of living, and how much they engaged in behaviors that are in accord with their values and life goals. These ratings will be collected throughout treatment as a process and outcome measure rather than a therapeutic tool. We expanded this rating form and adapted it for clients with anxiety disorders from a shorter Daily Willingness Diary introduced by Hayes, Strosahl, and Wilson (1999).
