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“This book is a celebration of mindfulness as a fully scientific, well-adapted system for an
active life in the West. Every intervention presented here is a living proof that Mindfulness
has become a prominent antidote to our Western malaise: a hyperactive, distracted and
scattered mind that knows no satisfaction. As part of this burnout society, in which we are
constantly everywhere and nowhere, this book, driven by both academic passion and deep
compassion, signifies a landmark in our understanding of human suffering and its cure.”
Shai Tubali, author of Indestructible You: Building a Self that cannot be Broken
“Cleary written, enjoyable and mind-expanding, this book is a must-read! The chapters go
well beyond providing a theoretical understanding, updating and organizing the expansive
variety of mindfulness-based work with page-turning case examples and wide-ranging
transformative activities that we could all begin using immediately.”
Francis Kaklauskas PsyD CGP FAGPA, lead editor of Brilliant Sanity:
Buddhist Approaches to Psychotherapy
“Encyclopaedic in its range, this book performs a vitally important role. It collates and
succinctly describes every significant mindfulness therapy and program, and so provides an
essential resource for anyone who practices or studies mindfulness, and anyone who would
like to benefit from it.”
Steve Taylor Ph.D., author of The Leap, and Spiritual Science.
Handbook of Mindfulness-Based
Programmes
SECTION I
Mindfulness programs in therapy5
SECTION II
Mindfulness programs in families77
SECTION III
Mindfulness programs in health-care141
SECTION IV
Mindfulness programs in education217
SECTION V
Mindfulness programs in children and adolescents265
22 Still Quiet Place: Sharing mindfulness with children and adolescents 267
AMY SALTZMAN
SECTION VI
Mindfulness programs at work295
24 Mindful leadership297
JUTTA TOBIAS MORTLOCK AND JENNIFER ROBINSON
25 Mindfulness practice and the law: Jurisight and the skillful means to
greet the legal profession 313
SCOTT ROGERS AND SARAH STUART
xii Contents
SECTION VII
Mindfulness programs in addiction325
SECTION VIII
Mindfulness programs in compassion355
SECTION IX
Mindfulness programs in psychological flourishing383
Index415
Chapter 1
Handbook of Mindfulness-Based
Programmes Handbook of Mindfulness-Based Programmes Itai Ivtzan
An introduction
Itai Ivtzan
When we think about mindfulness we frequently picture a monk, wearing orange robes,
sitting rigidly for hours, days, maybe even weeks, with his hands resting on his thighs and
without moving his body. Although we can indeed practice mindfulness in this way, it is only
one option amongst an infinite list of possibilities. This is because mindfulness is not about
what we do, or which posture we adopt; it is about our way of being. We practice mindful-
ness every time our mind (our attention) is one with the activity we are performing. Yes, it is
as simple as that. When your mind and activity are one, you are present in the moment; your
mind does not wander, and you are free of judgement, criticism, avoidance, and many other
cognitive processes that take place in our normal state of consciousness.
But what is that normal state of consciousness? It is usually characterised by contempla-
tion of things other than the activity in which you are engaged. For example, when you speak
to your friend while thinking about an email from your boss; when you read the email from
your boss while thinking about tonight’s date; when you sit with your date while thinking
about a task you need to do for work; when you complete this task while thinking of your
lunch; when you eat your lunch while thinking of your friend. This is a vicious circle in
which we are constantly anywhere but in the present moment. This creates a duality between
what we do and where we are (mentally). Such duality distances us from our experiences of
life, from ourselves, and from our loved ones. If we are not present as things happen, as we
feel and eat and talk and make love and write, we are not in touch with the heart of the expe-
rience, the essence of the moment. This is exactly what mindfulness therefore offers: a unity
of mind and action, a presence. When these come together our experiences are transformed.
We know from scientific research that being mindful changes our experiences, making them
more meaningful and enjoyable while enabling us to become more efficient and engaged
with life.
Mindfulness research has been conducted with many different groups and the results have
consistently demonstrated the important impact mindfulness can have on very different
experiences. For example, we now know that practicing mindfulness when we eat makes the
food taste better and makes us more aware of the point at which we have had enough and
need to stop eating. Practicing mindfulness when we have sex makes the experience more
sensual, enjoyable, and connected. And one final example, which I find wonderful because of
its mundanity, mindfulness has been found to have an extraordinary impact on the experience
of washing the dishes! In such as study, participants are randomly assigned to either “tradi-
tional” or “mindful” groups. The first group of participants washes the dishes in a traditional
way. This involves washing the dishes while thinking about different things (as most of us do
2 Itai Ivtzan
when we wash the dishes). This is the duality I referred to earlier: the activity (washing the
dishes) and the attention (wandering into thoughts and images that have nothing to do with
the activity at that moment) are disconnected, cleaving the here-and-now experience into two
elements that fight for control over one’s consciousness. The second group of participants,
however, washes the same number of dishes mindfully for the same length of time. What
does it mean to wash the dishes mindfully? If mindfulness is all about unity of activity and
attention, then all I would need to do is devote my full attention to the activity. For example,
I would notice the temperature of the water, feel the texture of the plates and cutlery, notice
the feel of the liquid soap as it touches my hand, become aware of how the soap smells;
these are all examples of presence. My mind is not wandering off into irrelevant thoughts
and instead is fully aware of and embracing the experience and activity of the moment. The
results of such studies indicate that participants in the “mindful” washing group exhibited
a significant increase in positive emotions and a corresponding decrease in negative emo-
tions. Such benefits were not found in the “traditional” washing group. The same pattern
of results can be seen in numerous other mindfulness studies: whatever the circumstances,
whatever the activity, integrating a mindful way of being into our lives offers a meaningful
transformation.
The discussion above lays the foundations for this book. We now realise that we can
implement mindfulness in any population, at any age, for any challenge, and in any circum-
stances – to support both individuals and groups. A nurse could be seeking mindfulness to
help her deal with patients, a teacher might need it to reduce burnout, students may find it
helps them to concentrate, employees could improve the quality of their relationships with
colleagues, the elderly could find it helps them accept the losses experienced with aging,
athletes could concentrate better and improve their performance, and therapists could deepen
their feelings of empathy with a client. However, each of these populations is different in
many ways, which needs to be taken into account in the delivery of mindfulness so that a
personalised and relevant experience is provided for each practitioner.
This realisation has initiated an abundance of mindfulness programmes in the West, each
comprising different practices that utilise a variety of exercises and creative approaches and
are constructed in a way that feels “right” for each specific practitioner or group of practition-
ers. For this book I have chosen to select well-established programmes, with a clear ration-
ale, which have demonstrated creativity and wisdom in their application of mindfulness.
These programmes have also been scientifically studied and have been shown to provide the
practitioner with a positive transformation.
The book is divided into sections, each covering a different theme or population. In each
section there is a list of chapters describing different mindfulness programmes. The first sec-
tion is Mindfulness programmes in therapy, which takes the reader through different thera-
peutic approaches that integrate mindfulness to deepen psychological healing. The second
section is entitled Mindfulness Programmes in Families and offers a variety of programmes
to support parenting, childbirth, relationships, and growing old. The next section, Mindful-
ness programmes in health-care, shows how mindfulness programmes can be integrated into
medical practice while also supporting people who are recovering from cancer, eating disor-
ders, and insomnia. As part of the mindfulness programmes in education this book offers a
variety of mindfulness practices for both teachers and students. The next section, Mindfulness
programmes in children and adolescents, focuses specifically on child-oriented mindfulness
programmes while the following section, Mindfulnessprogrammes at work, focuses on lead-
ership and law. The next section, Mindfulness programmes in addiction then describes two
Handbook of Mindfulness-Based Programmes 3
mindfulness-based approaches that can help with addiction and substance abuse. Mindful-
ness programmes in compassion, on the other hand, is a section in which the emphasis is
on the relationship between mindfulness and compassion, offering programmes that deepen
both self-compassion and compassion to others. The final section, Mindfulness programmes
in psychological flourishing, describes two mindfulness programmes that focus on flourish-
ing through strengths, hope, meaning, and other concepts derived from positive psychology.
Thus, this is an indisputably diverse group of sections and mindfulness programmes, provid-
ing the reader with a full spectrum of knowledge and experience of mindfulness applications.
When I see the long and varied list of mindfulness programmes in this book I feel both
excited and proud. Excited because of the incredible potential these programmes offer to
improve people’s lives, thereby making the world a slightly better place. Proud because in
the West we have taken an Eastern-based practice and translated it into a practice that is
relevant to the Western world in a 21st century marked by turmoil. I hope you enjoy this
wonderful development in the history of mindfulness practice.
Section I
Mindfulness programs
in therapy
Chapter 2
Introduction
Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999) is a trans-
diagnostic psychotherapy shown to be effective for a variety of problem areas, including
but not limited to mood and anxiety disorders (Bluett, Homan, Morrison, Levin, & Twohig,
2014; Twohig & Levin, in press). ACT is considered a contextual cognitive behavioural
approach to psychotherapy that has developed out of both traditional behaviour analysis
and contemporary interest in mindfulness and acceptance processes. The defining aspect of
contextual psychotherapies is an emphasis on targeting “the context and function of psycho-
logical events” rather than their content, often through the use of mindfulness and accept-
ance techniques (Hayes, Villatte, Levin, & Hildebrandt, 2011, pp. 157–158). The goal of
this chapter is to introduce ACT as a therapeutic approach. Furthermore, because ACT is a
product of a reticulated approach to scientific development, the critical elements underlying
ACT need to be introduced: its underlying philosophical assumptions and behaviour analytic
account of cognition.
regardless of their formal properties. A simple example is the relation between objects and
the nouns that label them, such as when humans learn that the spoken word “dog” is the
same as an actual dog, and the written word “d-o-g” is the same as an actual dog. As a result
of learning these two relations, a language-able human knows the written word is the same
as the spoken word even with no direct training regarding their equivalence. It is derived
automatically. This is expansive. It has been shown that this occurs with many other types of
frames such as comparatives (more than, bigger than, worth more). Thus, given the ability
to relate things, one can respond to just about anything without needing to have previously
interacted with it. The automaticity and expansiveness of this thinking process fits well with
how many mindfulness approaches conceptualize cognition; one good example is the rest-
less and frantic “monkey mind.”
Not only is language expansive and automatic, it also can transform experiences that are
“thought about.” More technically, the function of a stimulus can be transformed due to what
it is verbally related to. For example, if a child is taught that dogs are dangerous, the child
will likely show an emotional response to many dogs, the spoken word dog, and the written
word dog. A child might even avoid going to new places if told dogs might be there. One
clinically important feature of this is that therapists can either target the relational frames
themselves (the actual information), or the context that informs what function should be
transferred (and therefore the impact of the relations on behaviour). ACT uses acceptance
and mindfulness techniques to alter the context that informs the function to be transferred
(for instance, noticing a thought as just a thought versus relating to the thought as absolutely
true information that must be acted on).
unwelcome inner experiences, acceptance can be seen as the opposite strategy of experien-
tial avoidance: a pattern of attempting to reduce or avoid contact with unwanted inner expe-
riences, which narrows one’s repertoire of effective action and overall functioning (Hayes,
Wilson, Gifford, Follette, & Strosahl, 1996).
Defusion: Cognitive defusion describes the process of relating to thoughts in a non-
literal way. In other words, cognitive defusion is the ability to respond to thoughts as simply
thoughts, urges as urges, and sensations as sensations. This view contrasts with another com-
mon way that people relate to inner experiences: in terms of how truthful, logical, or rational
they are.
Present moment awareness: Present moment awareness, or contact with the present
moment, involves shifting and maintaining attention on what is occurring here and now.
Present moment awareness encompasses flexible attention to both external and internal envi-
ronmental stimuli and bears a strong similarity to the “attending” or “awareness” aspect of
popular definitions of mindfulness (e.g., Kabat-Zinn, 1994; Bishop et al., 2004; or Langer,
2000).
Self as context: Sometimes called a transcendent sense of self, self as context refers to
contact with oneself as an ongoing observer, aware of yet distinct from, one’s experience.
Self as context is contrasted with the more typical, pathological self as content, wherein an
individual overly identifies with the literal content that is used to describe them (such as
through their “self stories”). When individuals encounter a sense of self as context, they
report identifying with an observing frame of mind that is itself boundless. Self as context
10 Jennifer E. Krafft, et al.
means contacting a sense of being the container, rather than what is contained. For example,
you are the sky and your thoughts and feelings are passing clouds.
Values: Values refer to what is deeply and personally meaningful to an individual in terms
of how they act in the world. More technically, values are verbally constructed consequences
for patterns of activity that enhance the reinforcing qualities of engaging in that activity.
Values connect specific behaviours to their meaning in each moment. Values are different
from goals in that they are abstractions from meaningful patterns of activities, instead of
those activities themselves. For example, a father might have the goal of coaching his child’s
sports team, which is connected to the value of being a good parent. Because values are
abstractions, it is helpful to clarify them and explicate how they connect with daily life. Val-
ues function as a positive aspect of language which helps augment one’s focus on meaning-
ful, vital patterns of action (Wilson & Dufrene, 2009).
Committed action: ACT is ultimately a behavioural approach, which is to say that each
ACT process is a means to change how individuals function in the world. Committed action
describes the class of actions in which a person intentionally engages to move towards val-
ues-consistent goals. As such, some clarity in regard to values is necessary to engage in
committed action.
Empirical support
ACT is a transdiagnostic approach and has been applied to, and shown to be effective with,
an impressive breadth of issues, not all of which fit neatly within clinical diagnoses (A-Tjak
et al., 2015). Within the clinical realm, ACT has been shown to be effective for depressive
disorders (Twohig & Levin, in press), anxiety and OCD spectrum disorders (Bluett et al.,
2014), and substance use disorders (Lee, An, Levin, & Twohig, 2015), among other problem
areas. Readers interested in further information on the efficacy and effectiveness of ACT are
encouraged to investigate the meta-analyses published on this topic such as A-Tjak et al.
2015 and Öst 2014.
ACT in practice
Introduction
ACT is not defined by a specific set of techniques. Instead, at a fundamental level imple-
menting ACT involves targeting theoretically specified processes of change in order to foster
Acceptance and Commitment Therapy 11
psychological flexibility and increase quality of life (Westrup, 2014). This means that if a
clinician brings ACT exercises into the therapy room in a way that is not consistent with
enhancing psychological flexibility (for example, teaching a client to “name their mind” as
a strategy to control worry; Hayes et al., 1999), they are no longer implementing ACT. Con-
versely, if a therapist introduces a new metaphor or exercise that helps a client to recognize
thoughts as thoughts, this is defusion work, whether or not the exercise is described in any
ACT books or protocols.
The process-based nature of ACT allows clinicians freedom and creativity in discovering
how they can foster psychological flexibility in each of their clients. In turn, it requires a
solid understanding of the principles and processes that define ACT as well as focused, mind-
ful attention on what is happening in the therapy room (Luoma, Hayes, & Walser, 2007).
During a therapy session, therapists delivering ACT attend to the function of clients’
behaviour in each moment and identify and target psychological inflexibility as it shows
up, in order to encourage contact with new ways of behaving. ACT also tends to involve
extensive use of role-plays and metaphors to provide opportunities for experiential learning.
The number of sessions involved in a course of ACT can vary widely depending on the
problem area and progress observed over time. That said, clinical trials of ACT commonly
involve eight to twelve sessions (Bluett et al., 2014; Öst, 2014). ACT can be implemented in
group or individual therapy formats and have been successfully implemented in brief inter-
ventions such as workshops (Hayes, Pistorello, & Levin, 2012).
A relatively typical course of ACT will be described. However, as mentioned previously,
ACT is a therapy that entails immense flexibility. Depending on a client’s starting point and
progress, an ACT therapist may address each of the six psychological flexibility processes
in a single session or devote most of the course of therapy to a specific process. In addition,
while the ACT processes are introduced individually, the six processes of psychological flex-
ibility are interrelated at their core. For example, when introducing values, new areas of
fusion or avoidance may be encountered and it may be useful to shift to targeting mindful
acceptance. Each of the six processes supports one another and working on one often brings
up another.
One aspect of ACT that is distinct from many therapeutic orientations, although common
in mindfulness, is that the processes that are targeted in ACT are considered to be equally
applicable to clients and clinicians (Luoma et al., 2007). As such, it is important for clini-
cians to develop self-awareness with respect to ACT processes. For instance, a clinician who
finds herself avoiding in-session exposure because she is worried about causing distress can
recognize this as a type of experiential avoidance, open up, and consider how to proceed
in a way that is consistent with the value of helping her client grow. It can also be highly
beneficial for the therapist to model psychological flexibility. For instance, the therapist who
caught herself avoiding exposure could model awareness and willingness by sharing what
she noticed with her client. This stance can also help therapists to increase empathy and
develop a collaborative, egalitarian relationship.
Session overview
class of experientially avoidant behaviours that serve the purpose of attempting to control
these experiences can be identified, including internal attempts to suppress or alter unwanted
thoughts and feelings as well as avoidance of situations expected to trigger those thoughts
and feelings. For example, a client bothered by panic attacks may avoid not only places or
activities that occasion panic, but also engage in cognitive avoidance or distraction. This can
help clients recognize the range of behaviours that can serve as attempts to control and avoid
unpleasant internal experiences. Mindfulness is widely considered to include an attitude of
acceptance towards internal experience (Bishop et al., 2004), and this step lays the ground-
work for acceptance by building recognition of when and how non-acceptance occurs.
After identifying a set of experientially avoidant behaviours, these strategies are discussed
further to determine if they have worked to decrease suffering in the short term, or in the long
term, and what these strategies cost. This discussion is designed to engender a sense of “crea-
tive hopelessness,” a growing awareness that the current approach is not working to regulate
the internal events in order to begin developing the willingness to do something genuinely
different with those internal events. It is important to keep the focus on actual experience as
the ultimate judge of what works to control the internal events. The therapist’s job is not to
convince or persuade the client to give up a control agenda, but to help guide the client in
exploring his/her own experience.
Early sessions may introduce further discussion of the ineffectiveness of attempts at con-
trol, and the paradox that striving for control of internal experience may not only make
control more unachievable, but also lessen quality of life. This paradox can be highlighted
by drawing contrasts between the internal and external world. For instance, a clinician may
use the following technique:
“I’m going to ask you to do a few simple things, and observe how well you can do them.
I want you to try your very hardest to do them. The first thing is . . . don’t move your
arms. Keep working hard at that, do your very best, make sure your arms are not mov-
ing.” [Allow some time to notice how this works.]
“The next thing is . . . don’t think of a pink elephant. No matter what, make sure you
aren’t thinking about a big, pink elephant”. [Again, allow some time to notice how this
works.]
This exercise is concluded by asking how the two attempts compared. In general, it is easy
to not move, while the thought of a pink elephant comes automatically. There are several
metaphors that are also commonly introduced to develop a new perspective on the struggle
for control, such as falling into quicksand: the more someone struggles, the more they sink.
Acceptance
As clients begin to recognize that rigid emotional control is unworkable and costly, it is com-
mon to shift into introducing acceptance as an alternative. As mentioned previously, accept-
ance is an active embrace of internal experiences in each moment, with a stance of openness,
curiosity, and awareness – the opposite of experiential avoidance. This intentional, open atti-
tude towards experience is considered an essential component of mindfulness (Bishop et al.,
2004). Sometimes the term “willingness” is used in ACT because it better represents the
sense of acceptance as an active, warm stance. Acceptance is not the same as wanting or lik-
ing an experience, and this can be an important point of clarification. For example, it makes
Acceptance and Commitment Therapy 13
perfect sense that experiencing intrusive memories of a life-threatening car accident would
not be pleasant or desirable. However, letting those memories return without struggling with
them may enable the freedom to engage in new patterns of behaviour. As with the other ACT
processes, becoming more accepting is not an end in itself, but a way to draw closer to val-
ues. As such, exposure to painful thoughts and feelings, both in session and out of session, is
framed in the context of valued action. For example, an individual who struggles with binge
eating and values their health might be asked if they could notice and make space for their
painful emotions and urges to binge if it helped them get closer to their value of health.
There are numerous metaphors and exercises that can help in developing greater accept-
ance. In a commonly used exercise, clients write a difficult internal experience on a card and
are presented different ways of interacting with the card. First, the clinician holds the card
up and asks the client to push back against it. The client feels how much work it is to fight
against the card. Next, the card is crumpled up as small as possible. Other ways of avoid-
ing or distancing self from the difficult internal experience can also be acted out. Finally,
the client is asked to try letting the card sit on their open hands, and holding it gently, like a
butterfly. At each step, space is left to notice what it is like to interact with one’s experience
in this way. These types of experiential exercises can help to develop a sense of what accept-
ance might involve. As another example, mindfulness meditation exercises may be used to
help guide clients in actively noticing the experiences of difficult emotions, thoughts, and
sensations purely for what they are and without trying to fight them.
Cognitive defusion
Cognitive fusion refers to the human tendency to “buy into” cognitions, taking them liter-
ally and allowing them power over behaviour. Although the ability to talk about things
and have them treated as reality is essential for communication with others, there are other
times when taking language literally is less helpful. For example, when a client has the
thought, I’m not smart enough for college, and takes this thought literally, they are more
likely to quit studying or quit school entirely. Whether a thought is “positive” or “nega-
tive,” buying into thoughts can restrict behaviour in unworkable ways. For example, from
the thoughts “I’m a kind person” and “Kind people don’t get angry,” it may be derived that
it is necessary to avoid expressing anger or frustration even when this pattern of behaviour
damages the ability to have meaningful relationships. Defusion involves changing how one
relates to thoughts by perceiving them as what they truly are, in order to alter their impact
on behaviour. Bringing mindful awareness to thoughts helps to increase recognition of
thoughts as thoughts, supporting defusion. This ability to shift perspective on one’s inter-
nal experience is also referred to as “decentering” or “distancing,” and is a target of other
mindfulness-based interventions such as Mindfulness-Based Cognitive Therapy (Segal,
Williams, & Teasdale, 2002).
One classic defusion exercise, often referred to as “Milk, Milk, Milk” (Hayes et al., 1999),
involves quickly repeating a word or phrase. Eventually the word tends to lose its meaning
and be perceived as a series of sounds. This exercise is often started using neutral words or
phrases like “milk,” but later incorporating words or phrases that are more personally rel-
evant, such as “failure.” Another simple defusion exercise involves labeling the process of
thinking. For example, after having the thought, I’m broken, stating, “I’m having the thought
that I’m broken,” and even, “I’m noticing I’m having the thought that I’m broken,” can help
to engender distance from thoughts. Labelling thoughts in this manner can help foster a new,
14 Jennifer E. Krafft, et al.
less literal perspective on thoughts and develop a context in which thoughts do not necessar-
ily determine behaviour.
These cognitive defusion exercises provide examples of how ACT uses a number of non-
meditative experiential exercises to target processes often emphasized in mindful meditation
such as decentering/defusing from thoughts. This may arguably enhance clinician flexibility
in how cognitive fusion is targeted, increasing the ability to adapt to clients who struggle
with “eyes closed” mindfulness exercises and providing greater variation in mindfulness
training to support applying skills to relevant life situations.
Self as context
Developing a sense of self as context can also be an important part of ACT. This sense of
self as an ongoing observer of experience is cultivated through open awareness in the present
moment, and lies in stark contrast to a conceptual, verbally defined sense of self. It is com-
mon to be defined through self-narrative: for example, “I am a good mother,” “I am someone
who quits when things get hard,” “I am an activist.” While there is nothing problematic about
having these types of narratives about the self, they can contribute to the narrowing of behav-
iour when held tightly. For example, if being a “good mother” is essential to a woman’s sense
of self, she might avoid talking with her child about difficult topics such as substance use
or self-harm because it could involve learning information that might contradict the “good
mother” narrative. In contrast, the observing self provides a context for difficult thoughts
and feelings to occur without defining one’s experience. Self as context is often introduced
using metaphors such as “the chessboard” (Hayes et al., 1999). In exploring the metaphor,
thoughts and feelings that are struggled with are treated like pieces on the board. No matter
how much the pieces fight and battle, the board remains the same, and it can be moved in
any direction while holding all the pieces. Mindfulness practices such as meditation can also
bring clients in touch with a sense of the self as a context that contains, but is broader than,
internal experiences.
Acceptance and Commitment Therapy 15
Values
Values are flexible in the sense that there are generally many different behaviours that can be
linked to a specific value, and the awareness that these behaviours are tied to a value makes
engaging in them more reinforcing. Values are not goals to be attained, but qualities of action
that can be contacted in each moment. For instance, a health goal might be completing a 5k
run, while the value of health could be contacted in every moment of training and nourishing
one’s body along the way. A life connected with values is vital, engaged, and meaningful. All
work in ACT is designed to enable movement towards values. As such, every session tends
to involve touching on values at least briefly. However, it may make sense to devote several
sessions to the topic of values, particularly if values are unclear or values are driven by fear
or compliance. There are many exercises and tools available that can help to clarify values.
One popular one is the tombstone exercise (Hayes et al., 1999), which involves thinking to
the future and considering how one would want to be remembered after dying in order to
identify one’s most essential values. Mindfulness and acceptance, as described in the four
processes above, support the ability to pursue values even when difficult thoughts and feel-
ings show up.
Committed action
ACT is fundamentally a behaviour therapy, and the goal of a course of ACT is to develop
expanding patterns of behaviour that are consistent with values. As such, all the other pro-
cesses are important to the extent that they enable engagement in value-driven, committed
action. In therapy, this often takes the form of behavioural commitments linked to goals and
values with the support of the other ACT processes. This process is similar to traditional
behaviour therapy – for example, behavioural commitments may involve exposure to social
interaction for a person with social anxiety, scheduled smoking for a smoking cessation pro-
gram, or commitments to engage in meaningful actions towards a partner in couples therapy.
However, behavioural change is always linked back to values, which can entail a shift in
framing when introducing traditional behavioural methods such as exposure or behavioural
activation that are typically framed as a way to regulate emotions (Hayes et al., 2012). When
difficulty is encountered in following through on a commitment, this often indicates work is
needed in another ACT process. For example, the client who approaches a new social situa-
tion may become fused with thoughts such as no one here likes me, leading them to experi-
ence distress that they are unwilling to make room for, and leave the situation. Committed
action is woven throughout treatment, but it is particularly emphasized in later sessions, after
the development of mindfulness skills such as greater awareness, willingness, and defusion,
with one to two sessions (or more) focused on committed action as needed.
Termination in ACT is not based on symptom reduction, but on the development of
psychological flexibility. The most important evidence of progress is seeing the client’s
behaviour expanding in ways that allow living a more meaningful, engaged life. If a client
struggling with depression is continuing to experience self-critical thoughts, but finds that
he can hold those thoughts in mindful awareness, make room for them, and still engage in
meaningful activities, then treatment has been successful from an ACT perspective. Doing
what works to support clients in living a life that they value is what defines ACT above all
else. As such, ACT makes extensive use of mindfulness skills and techniques, but they are
16 Jennifer E. Krafft, et al.
always employed towards the purpose of enabling clients to behave differently, in a manner
more consistent with their values.
Online resources
To learn more about ACT, related mindfulness-based and contextual cognitive behavioural
therapies, or the basic research underlying this work, you can visit the Association for
Contextual Behavioral Science (ACBS) at https://contextualscience.org. ACBS is an inter-
national professional community that is the intellectual “home” for ACT among other con-
textual behavioural therapies. The website offers a vast array of resources for professionals
who join ACBS including access to ACT treatment protocols, videos, audio files, measures,
publications, and training opportunities.
References
A-Tjak, J. G. L., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A. J., & Emmelkamp, P. M. G.
(2015). A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant
mental and physical health problems. Psychotherapy and Psychosomatics, 84, 30–36.
Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., . . . Devins, G. (2004).
Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11,
230–241.
Bluett, E. J., Homan, K. J., Morrison, K. L., Levin, M. E., & Twohig, M. P. (2014). Acceptance and
Commitment Therapy for anxiety and OCD spectrum disorders: An empirical review. Journal of
Anxiety Disorders, 28, 612–624.
Fletcher, L., & Hayes, S. C. (2005). Relational frame theory, acceptance and commitment therapy, and
a functional analytic definition of mindfulness. Journal of Rational-Emotive and Cognitive-Behavior
Therapy, 23, 315–336.
Hayes, S. C., Barnes-Holmes, D., & Roche, B. (Eds.). (2001). Relational Frame Theory: A Post-Skin-
nerian account of human language and cognition. New York, NY: Plenum Press.
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment
Therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44, 1–25.
Hayes, S. C., Pistorello, J., & Levin, M. E. (2012). Acceptance and Commitment Therapy as a unified
model of behavior change. The Counseling Psychologist, 40, 976–1002.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An expe-
riential approach to behavior change. New York, NY: Guilford Press.
Hayes, S. C., Villatte, M., Levin, M., & Hildebrandt, M. (2011). Open, aware, and active: Contextual
approaches as an emerging trend in the behavioral and cognitive therapies. Annual Review of Clini-
cal Psychology, 7, 141–168.
Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoid-
ance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Jour-
nal of Consulting and Clinical Psychology, 64, 1152–1168.
Kabat-Zinn, J. (1994). Wherever you go, there you are. New York, NY: Hyperion.
Langer, E. J. (2000). Mindful learning. Current Directions in Psychological Science, 9, 220–223.
Lee, E. B., An, W., Levin, M. E., & Twohig, M. P. (2015). An initial meta-analysis of Acceptance and
Commitment Therapy for treating substance use disorders. Drug and Alcohol Dependence, 155, 1–7.
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therapy skills-training manual for therapists. Oakland, CA: New Harbinger.
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parce que les femmes maigres ne m’intéressent pas.
— Tu trouves vraiment qu’elle est maigre ? demanda Daniel.
— Comme elle n’est pas assez grosse pour que je me sois
donné la peine de la regarder longtemps, je ne me suis jamais rendu
compte de son degré de maigreur. Elle est au-dessous du poids que
j’exige : c’est tout ce que je puis te dire.
Daniel se taisait. Julius alla chercher les journaux illustrés, après
avoir demandé en vain si on ne pouvait pas aller quelque part, au
Casino ou à la Scala.
Berthe Voraud en aime un autre : cette révélation a un peu ahuri
Daniel. Mais il n’en éprouve aucune douleur, et se demande même
s’il n’en est pas un peu content, au fond.
Il ne renonce pas à ses projets de conquête. Il entrera en
concurrence — très discrète d’ailleurs et très prudente — avec
André Bardot, sur lequel, pense-t-il, il aura facilement le meilleur. Il
lui manque, pour le moment, les qualités extérieures d’André, mais il
possède, lui, une âme unique, une âme spéciale, qu’il s’agit
simplement de montrer, et qui doit fatalement conquérir le cœur de
Berthe. Il aime mieux, au fond, avoir un rival, que de se trouver tout
seul avec Mlle Voraud. Elle n’est plus, puisqu’elle aime, la jeune fille
surhumaine et inaccessible qu’il s’est imaginée. Il n’eût pas admis, si
elle l’eût aimé déjà, qu’elle pût en aimer un autre. Mais comme elle
aime quelqu’un, et que ce quelqu’un n’est qu’un autre, c’est lui,
Daniel, qu’elle finira nécessairement par aimer.
Il était confiant en lui-même. Il aimait la lutte, quand personne ne
savait qu’il luttait, et ne pouvait le forcer à lutter, quand il restait
maître de combattre à son heure, c’est-à-dire pas immédiatement.
Il boutonna son paletot, dit à Julius : « Nous allons à la Scala. »
Puis il frappa d’un coup sec la table de marbre, et paya les deux
mazagrans. C’était d’ailleurs son tour.
VII
INTERMÈDE
» Berthe Voraud. »