To begin with, the conceptualization of what may cause and maintain anxiety disorders is very consistent with an ACT model, in that anxiety disorders have unwillingness and avoidance at their very core. Individuals with anxiety disorders may take heroic steps to avoid internal bodily sen-sations associated with panic, feelings such as fear and anxiety, and all manner of situations and circumstances that are likely to occasion anxiety and its correlates. Thus, a model of psychopathology that has experien-tial avoidance at its core is extremely relevant for this category of prob-lems. It is certainly natural up to a certain point to try to avoid experiences that raise anxiety and fear; however, when strategies of avoidance and escape begin to be applied rigidly and inflexibly to anxiety and fear, as well as to the situations that are likely to trigger such reactions, then normal anxiety and fear may begin to become ‘disordered’ (Eifert and Forsyth, 2005). Barlow’s (2002) well-known model of anxious apprehen-sion can easily be viewed through an ACT lens. In this model, anxiety is described as ‘a future-oriented mood state in which one is ready or pre-pared to attempt to cope with upcoming negative events’ (Barlow, 2002:
64). This model goes on to describe two primary methods of attempting to cope with anxiety: (1) avoidance of situations that provoke anxiety or the internal experiences of anxiety; and (2) heightened attempts at planning and problem solving through worry in an attempt to avoid negative affect.
Based on this analysis, the dual concentration in ACT on reducing avoid-ance and decreasing fusion with cognitive content is especially germane.
For the anxious client who presents with a focus on avoiding anxiety at all costs, the application of ACT is generally marked by a strong emphasis in the early stages on the creative hopelessness and willing-ness aspects of treatment. Such clients have been treating their anxiety as if it is something very dangerous. Thus, the therapist will work carefully to demonstrate the futility of struggling with anxiety. The quicksand metaphor and other exercises identified in Chapter 3 are core interventions for this purpose. Clients who have been struggling with anxiety for long periods of time have generally tried many different things in order to avoid or escape their anxiety, resorting to a wide vari-ety of efforts at internal and external control. It can be helpful for the therapist to ask a question such as, ‘When you consider just how much time, effort and energy you have put into trying to get rid of anxiety, doesn’t it seem a little strange that it hasn’t gotten any better – that, in fact, it may have even gotten worse? With any other project or goal in life, if you had put this much effort in, don’t you think you would have seen results by now?’ Clients may not know what to make of this line of questioning at first, but they are generally able to relate to the experi-ence described, in which the harder they have tried to rid themselves of anxiety, the worse the anxiety has become.
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This work of Creative Hopelessness is truly key for working with anxiety disorders, as individuals with these problems have been trying desperately over time to do anything they can not to experience anxiety and other related thoughts, feelings and bodily sensations. It can thus seem terrifying when the therapist (whether in ACT or in CBT) asks the client to begin to approach those experiences that the client has made extraordinary efforts to avoid at all costs. Through metaphors and exer-cises, the ACT therapist seeks to help clients recognize that control efforts have not truly been working to reduce their anxiety over time anyway and may have even made things more problematic.
Another feature of anxiety disorders that makes an ACT approach particularly relevant is the fact that anxiety and worry are typically very future-focused. By definition, the future can only be imagined because of the verbal abilities that allow humans to project forward in time in their imagination. Because of this excessive fixation on the future, approaches that are focused on mindfulness and present-moment awareness are very appropriate for ACT treatment of anxiety disorders.
CBT approaches also recognize the role of thoughts and other verbal behaviour in the spectrum of anxiety disorders. However, rather than asking clients to explore the accuracy of and evidence for their thoughts, ACT practitioners work with their clients to begin to defuse from these thoughts and see them for what they are (e.g. ‘milk, milk, milk, milk’).
Thoughts such as, ‘my heart is beating so fast that I might die’, are not examined for the probability that the content of the thought will actu-ally come true. Instead, the ACT therapist uses defusion exercises to demonstrate that minds are simply thought-generating machines, and we do not have to take their products literally.
Once these concepts have been introduced, then ACT-based approaches to anxiety will feature a strong focus on the most reliably effective com-ponent of existing approaches to the treatment of anxiety: exposure. As described in Chapter 8, ACT-based exposure efforts are not targeted toward habituation or the extinction of anxiety responses. Instead, the rationale of increasing psychological and behavioural flexibility is pro-vided. Such exposure work can be done in vivo, imaginally or interocep-tively with the client’s own bodily sensations. Regardless of the type of exposure practised, the ACT therapist will suggest that if it is the case that avoidance and struggle have gotten the individual more and more stuck, then the antidote to this problem is finding a new way to approach these experiences.
Interoceptive exposure is used in many common approaches to anxiety disorder treatment. In such practices, the client is instructed to engage in a variety of low-risk physical activities (e.g. spinning in a chair, breathing through a straw, hyperventilating) that are likely to produce the internal experiences of anxiety and panic. An ACT approach might use several of these very same techniques to bring about the private experiences associated with anxiety, either in the session or as homework.
78 Essentials of Acceptance and Commitment Therapy
However, rather than teaching the client ways of reducing anxiety when these symptoms are present and suggesting that anxiety symptoms will go down over time with practice, the ACT therapist will use these oppor-tunities to coach the client on practising willingness and acceptance, rather than avoidance and escape. Glaser and colleagues (2009) suggest that the breath-holding exercise from Get Out of Your Mind and Into Your Life (Hayes and Smith, 2005) can be used in this way as well. For example, the client may be asked to attempt to hold his breath for as long as he can, without providing any additional instructions, assuming that the client will naturally begin by using his characteristic avoidance and control strategies. Later in the same session or later in a course of treatment, the client can again be asked to practise holding his breath, but from a stance of acceptance, in which he chooses to be willing to experience the sensations and feelings that arise without fusing with his catastrophic thoughts. In addition to seeing which method leads the cli-ent to be able to hold his breath longer, he is also encouraged to share what was different about those two approaches to experiencing challeng-ing thoughts, feelchalleng-ings and bodily sensations.
Although willingness and defusion are essential components of an ACT-based treatment for anxiety disorders, it is important to remember the role of values in motivating the hard work of exposure and acceptance. As described above, it can be terrifying to ask individuals who have been fighting anxiety to begin to face and approach their ‘anxiety monsters’. On the part of the therapist, it would not be fair to ask the client to do so with-out a valid means of justifying such hard work. In ACT, the motivating factor is the idea that by letting go of avoidance and control, the client has the possibility of regaining a life that she can truly value. The idea of being able to move forward with flexibility in the service of those things that are important to the client is what makes the hard work of exposure worthwhile. However, this concept may initially be difficult for some cli-ents, because their chronic avoidance may have led to significant levels of value constriction. Because these clients have spent so long revolving their lives around their unwillingness to experience anxiety, it may initially be challenging to have clients identify what is truly important to them.
However, when individuals realize that there is a possibility that they can regain their lives, it can be exceptionally powerful. For this reason, Orsillo and colleagues (2004) suggest that the idea of values-based action be introduced early in therapy and reinforced throughout the course of treatment when working with individuals with anxiety problems.
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