acceptance and commitment therapy group therapy web viewacceptance and commitment therapy group...

Acceptance and Commitment Therapy Group Therapy Protocol

Addictions Intensive Outpatient Program PTSD/Substance Use Dual Diagnosis Program

[Unpublished Therapy Manual. 2007]

1

Author Acknowledgements

VA Maryland Health Care System Acceptance and Commitment Therapy (ACT) Team

Minu AghevliSonja BattenPaul Benson

Melissa DeckerJason DeViva

James FinkelsteinSharon Kelly

Valdone KuciauskasCarol Mahoney

Mark MannSarah MoellerLorie Morris

Sushma RobertsAndrew Santanello

2

Acceptance and Commitment Training (ACT) Program Philosophy Statement

Pain is inevitable, suffering is optional.-- Sylvia Boorstein

We know that individuals with substance abuse problems or PTSD have a tendency to avoid painful memories and engage in behaviors to distance themselves from their pain. Although these strategies may have worked in the short term, we believe that efforts at avoidance are ineffective, and even harmful, in the long run. This program is about becoming willing to make more space in our lives so that we are able to hold all the painful thoughts, memories and experiences life has dealt us without dodging them through the use of substances, AND at the same time move in the direction we value.

We strive to find meaning in our lives by letting ourselves and others know what is really important to us – what we value most. This treatment isn’t about what is “good” or “bad,” or what is “right” or “wrong;” the most important question at stake here is, “How well has this been working for me?” One of our most important tasks is to honestly take stock of what actions, relationships and life activities will help us live a vital and valued life. For many of us, past or present behaviors such as substance use, avoidance due to PTSD, or other difficulties may be causing us to behave in a way that is out of line with our values.

In all of our activities in the ACT Program, whether they be group therapy, individual counseling, or informal interactions with each other, we will work on:

Willingness to experience the full range of feelings, memories, and thoughts that we have on a daily basis, without attempting to get rid of or avoid those that we find difficult or uncomfortable

Being able to make an honest evaluation of our actions and beliefs in order to determine how well they are working

Coping skills as alternatives for avoiding or using substances Developing and participating in a social network Commitment to moving forward in our lives, in a direction determined by our

individual values

This treatment is about living in a way that is rich, full, and vital, and that lines up with our values. In this program, we choose life.

3

Table of Contents

Title Page 1

Authors 2

Mission Statement 3

Week One: Radical Hope

Monday CurriculumQuiet Reflection 4Group Outline 5Homework Assignment 11

Wednesday CurriculumQuiet Reflection 12Group Outline 13Journal Group Assignment 16

Friday CurriculumQuiet Reflection 17

Week Two: Control Versus Willingness




Week Three:


Wednesday Curriculum

4

Quiet Reflection 34Group Outline 35Journal Group Assignment 39


Week Four:




Week Five:




Patient Handouts 64

5


Monday Quiet Reflection

Workability Quotes

"Life is "trying things to see if they work." Ray Bradbury

“I cannot say whether things will get better if we change; what I can say is they must change if they are to get better.”

Georg Christoph Lichtenberg

“If the only tool you have is a hammer, you tend to see every problem as a nail.” Abraham Maslow

The definition of insanity: Doing the same things you’ve always done and expecting different results.

6


Monday Curriculum

Group leaders will need a shovel for the group.

Philosophy StatementRead over the program philosophy statement (See Page 3). Have one person stand up and read each paragraph.Ask group participants to reflect on what they connected with in the statement. Ask if there's anything that surprises or scares them in that statement. Allow for discussion and sharing between the patients. This process generally takes about 20 minutes.

Read the three Quiet Reflection quotes (See page 6) and ask the group which one they relate most to. For the first quote, point out the playful nature of trying new solutions. For the second quote, try to have people reflect on the necessity of change, even if the outcome is not promised. For the third quote, point out the need to use the right tool for the right job (This can be helpful to set up for the digging part of the person in the hole metaphor). This process generally takes about 10 minutes.

Next, present the Man in the Hole metaphor. Ask people to respond to the metaphor and try to get people to focus on the need to put down the shovel, even if you don't know what you're going to do next.

“Life is one damn thing after another. Our job is to make sure it’s not the same damn thing after another.”

Man In The Hole MetaphorThe situation you are in seems a bit like this. Imagine that you’re placed in a field, wearing a blindfold, and you’re given a little bag of tools. You’re told that your job is to run around this field, blindfolded. That is how you are supposed to live life. And so you do what you are told. Now unbeknownst to you, in this field there are a number of widely-spaced, fairly deep holes. You don’t know that at first--you’re naive. So you start running around and sooner or later you fall into this large hole. You feel around and sure enough you can’t climb out and there are no escape routes you can find. Probably what you would do in such a predicament is take the bag of tools you were given and see what is in there: maybe there is something you can use to get out of the hole. Now suppose that there is a tool in that bag but what you’ve been given is a shovel. It’s seemingly all you’ve got. So you dutifully start digging, but pretty soon you notice that you’re not out of the hole. So you try digging faster, and faster. But you’re still in the hole. So you try big shovel fulls, or little ones, or throwing the dirt far away or not. But still you are in the hole. All this effort and all this work and oddly enough the hole has just gotten bigger and bigger and bigger. Hasn’t it? So you come in to see me thinking “maybe he has a really huge shovel--a gold-plated steam shovel.” Well, I don’t. And even if I did I wouldn’t use

7

it because digging is not a way out of the hole--digging is what makes holes. So maybe the whole agenda is hopeless--you can’t dig your way out, that just digs you in. This metaphor is extremely flexible. It can be used to deal with many beginning issues. In the interaction with the client, the therapist can build out the metaphor to address these specific issues that the client raises or that you think are there. It is also useful to try to integrate these responses into the ongoing metaphor, as demonstrated by some of the following scripting:

1. Maybe I should just put up with it.“You’ve tried other things. You’ve tried to tolerate living in a hole. You sit down and twiddle your thumbs and wait for something else to happen. But that doesn’t work and besides, it’s just no fun living your life in a hole. So when you say “put up with it” or “give up” what I hear is secretly staying with the same agenda (digging your way out) but no longer trying because it doesn’t work. I’m suggesting something else. I’m suggesting changing the agenda.”

2. I need to understand my past.“Another tendency you might have would be to try and figure out how you got in the hole; you might tell yourself, “Gee, I went to the left, and over a little hill, and then I fell in.” And of course that is literally true; you are in this hole because you walked exactly that way. Your exact history brought you here. But notice something else. Knowing every step you took does nothing to get you out. And besides--remember you are blindfolded--even if you had not done exactly that, and you’d gone somewhere else instead. In this metaphor, you might have fallen into another hole anyway, because there are lots of holes to be found. So you found anxiety, someone else found drug abuse, someone else found bad relationships, someone else found depression. Now I’m not saying your past is unimportant, and I’m not saying we won’t work on issues that have to do with the past. The past is important but not because figuring it out let’s you escape emotional pain. It is only the past as it shows up here and now that we need to work on--not the dead past. And it will show up in the context of you moving on with your life. When it does, we will work on it. But dealing with the past isn’t a way out of the hole.”

3. Am I responsible for these problems?“Note that in this metaphor, you are responsible. Responsibility is recognizing the relationship between what we do and what we get. Did you know that originally the word “responsible” was written “response able”? To be responsible is simply to be able to respond. So, yes, you are able to respond. And yes your actions put you in the hole and your actions can take you out. Response-ability is acknowledging you are able to respond and were we to do so, the outcome would be different. If you try to avoid responsibility there is a painful cost: if you cannot respond, then truly nothing will ever work. But I’m saying digging is hopeless, not you are hopeless. So don’t back up from responsibility--if you have an ability to respond, then there are things you can do. Your life can work.”

4. Should I blame myself?“Blame is what we do when we are trying to motivate people to do something--to change or to do the right thing. But you look plenty motivated to me. Do you need more? Do you

8

need to buy “I’m at fault”? Blame is like standing at the edge of the hole and throwing dirt on top of the person’s head and saying “Dig out of here! Dig out of here!” The problem with blame in this situation is that it is useless. If the guy in the hole has dirt thrown down on his head it won’t make it any easier to get out of the hole. That doesn’t help. When your mind starts blaming you, does buying blaming thoughts strengthen you or weaken you? What does your experience tell you? So if you buy blame from your mind, go ahead, but then be response-able about that. If you buy into that you will be doing something that your experience tells you doesn’t work.”

5. What is the way out?“I don’t know, but let’s start with what isn’t working. Look, if you still have an agenda that says “dig until you die,” what would happen if you were actually given a way out? Suppose someone put a metal ladder in there. If you don’t first let go of digging as the agenda you’d just try to dig with it. And ladders are lousy shovels--if you want a shovel you’ve got a perfectly good one already.”

6. The need to give up first.“Until you let go of the shovel you have no room to do anything else. Your hands can’t really grab anything else until that shovel is out of your hand. You have to let it go. Let it go.”

7. A leap of faith.“Notice you can’t know if you have any options until you let go of the shovel, so this is a leap of faith. It is letting go of something, not knowing if there is anything else. In this metaphor you are blindfolded after all--you’ll only know what else is there by touch and you can only touch something else when the shovel is out of your hands. Your biggest ally here is your own pain. That is your friend and ally here because it is only because this isn’t working that you’d ever even think to do something as wacky as letting go of the only tool you have.”

8. The opportunity presented by suffering“You have a chance to learn something most people never will--how to get out of holes. You would never have had a reason to learn it if you hadn’t fallen into this hole. You’d just do the rational thing and muddle through--running around blindly your whole life, perhaps. But if you can stay with this, you can learn something that will change your life. You’ll learn how to disentangle yourself from your own mind. If you could have gotten away with it --more or less--you’d never have done that.”

HomeworkFinally, ask one person to volunteer to give examples of what types of things they've done that are digging - things that may have looked like they'd help, but really just got them deeper in the hole. Try to get at least 2-3 clear, operational examples. This is set-up for handing out the homework for the assignment group the next day. Then, hand out the assignment, where they're all asked to come up with 3 things they do that are digging. Ask someone to read the assignment out loud and explain that they each need to have it

9

done by tomorrow morning, regardless of whether they come to assignment group or not. This process takes 5+ minutes.

10


Homework Assignment

As we discussed today, we all sometimes make the mistake of trying to dig our way out of a hole. Of course, this only gets us deeper and deeper in the hole. For Wednesday, I’d like you to work on identifying some of the things that you do that get you more and more STUCK!

In preparation for next week’s group, please identify 3 things that you do that are “digging” in your life – things that you do that are meant to solve your problems but just seem to work in the short term, don’t work at all, or maybe even make things worse. Anything that keeps you stuck would be considered “digging.”

Digging #1:

Digging #2:

Digging #3:

11


Wednesday Quiet Reflection

12



Review of Radical Hope

13

For those who missed the Monday education group and didn't hear the hole metaphor, or for those who slept through it the first time, ask a patient volunteer to review the basic premise of the metaphor for the group.

Review of Control/Digging StrategiesAsk group participants to come up with a comprehensive list of the things that they identified as digging for their homework the previous day. [The basic query is: what are all the things that you've tried to do to deal with your difficult thoughts, feelings, and memories over the years?] This can be a huge laundry list containing:

DrugsAlcoholOversleepingOvereatingIsolatingAngry outburstsSexLyingManipulatingGeographical movesUsing peopleOverworkingOveranalyzed thingsAnd a million other things that they may come up with individually

Point out that all of the things on this list are also the things we mean when we talk about someone as a "dry drunk." Someone who is engaging in behaviors similar to what an addict does, even though they're not actively using.

Avoidance Ask the group what all of the things on the list have in common. Usually someone can come up with some phrase like, "avoidance," or "escape," or "they're all things that you do, but that don't ever do anything to really fix the underlying problem." Basically you want to get to the point where you can label these general behaviors escape or avoidance.

Ask if anyone thinks this is sort of strange. "You're smart people, you've worked hard, you tried hard. If you put as much effort into anything else as you have at trying to avoid all this stuff, then you would have been really successful at anything you were trying to do. And sometimes it even seems like it makes things better ………… in the short term. Yet here you are again. Does anyone smell a rat here?" Let people comment and see if they can get in contact with the futility of the avoidance strategy.

"And has anyone in here ever had the experience that if though it doesn't seem that it should work that way, that sometimes the MORE you struggle, the more difficult things get?" Usually about a quarter of the group can relate to this.

14

"So, let's start with where you are. Do you feel stuck? Does anyone in here feel like they're in that hole we talked about on Monday, right now? Ok, well good - then the first thing we need to do is to put down the shovel. And the good thing is that now we've come up with a long list of things that the folks in this room use as a shovel. So, if you can at least STOP doing those things, then you're making progress. Then at least you won't be making the hole any deeper."

The Quicksand MetaphorWe have a problem here and that is that your mind tells you to do what doesn’t work, because it can’t see anything else to do. It would be like if you were caught in quicksand. Naturally, you’d try to get out. But almost everything you’ve learned about how to get out will cause problems in quicksand. If you try to walk, jump, climb, or run, you just sink in deeper because you end up trying to push down on the sand. If you struggle, wiggle, push with your hands, or crawl, you sink in deeper. Often, as people sink, they get panicky and start flailing about, and down they go. In quicksand, the only thing to do is to create as much surface area as possible, to lay out on the quicksand, getting everything you have in full contact with it. It’s like that. We need to get everything you have in full contact with what you’ve been struggling with, but without more struggle. That will be hard - not hard meaning effortful, but hard meaning tricky. It’s tricky because your mind tells you to do what doesn’t work, because it can’t see anything else to do. And it has learned this so well that you can’t just tell it to stop and expect that it will.

Next, present the Driving with the Rearview Mirror metaphor. The point of this metaphor is to take their hands off the thing they've been using to try to steer their life (the shovel, avoidance, the rearview mirror) and begin to focus on what might actually work:

Driving the Car with the Rear-View Mirror MetaphorIt’s as if you got into your car and took off down the highway. Unfortunately, whoever taught you how to drive told you that the way to steer the car is by holding onto and turning the rear-view mirror. Now, you might be able to go a long way once you start down the road without anything much happening, depending on whether the road you’re on is straight, or whether there is much oncoming traffic, and so on. Eventually, however, the car is going to crash. But the what you do is dust yourself off, start the car again, grab the rear-view mirror, and start driving again. But you keep crashing! The problem isn’t with the car, or with the driver; the problem is that you can’t steer a car with the rear-view mirror. This kind of therapy is about teaching you to put your hands on the steering wheel instead of the rear-view mirror. This therapy isn’t about where you have been so much as where you are going and how to get there.

If there is still time, or if this metaphor fits better on a given day than the Driving with the Rearview Mirror, present the Feedback Screech Metaphor:

The Feedback Screech MetaphorYou know that horrible feedback screech that a public address system sometimes makes? It happens when a microphone is positioned too close to a speaker. Then, when a person

15

on stage makes the least little noise, it goes into the microphone, the sound comes out of the speakers amplified and then back into the mic, a little bit louder than it was the first time it went in, and at the speed of sound and electricity, it gets louder and louder until, in split seconds, it’s unbearably loud. Your struggles with your thoughts and emotions are like being caught in the middle of a feedback screech. So what do you do? You do what anyone would. You try to live your life [whispering] very quietly, always whispering, always tip-toeing around. You can’t really live without making noise. But notice that in this metaphor, it isn’t how much noise you make that is the problem. It’s the amplifier that’s the problem. Our job in here is not to help you live your life quietly, free of all emotional discomfort and disturbing thoughts. Our job is to find the amplifier and to take it out of the loop.

Finally, talk to the group about where we're going from here. Tell them that the work of therapy from now on will be on identifying their steering wheel and learning how to take control of their lives, rather than trying so hard to control their emotions. But this isn't something that we can directly instruct them how to do:

The Baseball MetaphorThere is something you can do in this situation, but I can’t just lay it out logically. Even if I did, it wouldn’t help. It is something like hitting a baseball. It doesn’t help to have too much analysis about how to do it. Yogi Berra said that the best thing to do was “don’t think, just hit.” If you ever went to the plate thinking a lot about how to hold the bat, the right position to take, where your wrists should break, and so on, chances are you didn’t hit the ball very well. You’d be off in the ozone thinking while the ball went past. Your hand, arms, and eyes know a lot more about how to hit than the verbal side of you does. This is like that. There is a skill to be learned, but it can’t be learned through a whole lot of literal, logical, linear language.

Journal Group AssignmentHand out the Journal Group Assignment.

16


Journal Group Assignment

1. Like in the quicksand metaphor, could you be willing to stop struggling with your own thoughts, feelings, memories, bodily sensations, etc. – and instead just stay still, and be in contact with them? What reactions do you have to that idea?

2. What would you have to do in order to stop struggling? Imagine yourself actually doing this. What would it look like? What would you be doing instead?

17


Friday Quiet Reflection

Imagine that the course of your life depends on you steering a car down a road in the direction of what’s important to you. And so at the beginning of this process, you get into your car and take off down the highway. Unfortunately, whoever taught you how to drive told you that the way to steer the car is by holding onto and turning the rear-view mirror.

Now, you might be able to go a long way once you start down the road without anything much happening, depending on whether the road you’re on is straight, or whether there is much oncoming traffic, and so on. Eventually, however, the car is going to crash. So, what you do is dust yourself off, start the car again, grab the rear-view mirror, and start driving again. But you keep crashing!

The problem isn’t with the car, or with the driver; the problem is that you can’t steer a car with the rear-view mirror! What we’re working on here is about teaching you to put your hands on the steering wheel instead of the rear-view mirror. Our focus is less on where you have been, and more on where you are going and how to get there.

Reflection Question: Have I been steering my life using the steering wheel, or the rearview mirror? What would I need to do to plant my hands more firmly on the steering wheel?

18

Week Two: Control vs. Willingness


Willingness Quotes

“If nothing changes, nothing changes.” Ernie Larson

“If you do what you always did, you’ll get what you always got.” Moms Mabley

Reflection Question: How can you stop doing what doesn’t work AND are you willing to try something different?

Requires ACCEPTANCE and WILLINGNESS and COURAGE

COURAGE (literally, to have heart): the attitude of facing and dealing with anything recognized as difficult or painful, instead of withdrawing from it

19


Monday Curriculum

AcceptanceFirst, read the following paragraph from the Big Book:

“And acceptance is the answer to all my problems today. When I am disturbed, it is because I find some person, place, thing, or situation—some fact of my life—unacceptable to me, and I can find no serenity until I accept that person, place, thing, or situation as being exactly the way it is supposed to be at this moment. Nothing, absolutely nothing happens in God’s world by mistake. Until I could accept my [addiction], I could not stay sober; unless I accept life completely on life’s terms, I cannot be happy. I need to concentrate not so much on what needs to be changed in the world as on what needs to be changed in me and in my attitudes.” — “Doctor, Alcoholic, Addict.” Alcoholics Anonymous (the “Big Book”), p. 449

Ask the group to reflect on what they connected with in this statement. Connect this back to principles of ACT and how they have struggled against acceptance in the past. Relate this explicitly to suffering they have experienced in their lives and attempts to control internal events.

Review of Creative HopelessnessReview the main points from the curriculum of Creative Hopelessness. Have the group identify with the futility of continuing to try things that don’t work (“Doing the same thing and expecting different results.”). Relate this to the problem people typically have with Step One in AA Twelve Steps – Admit the powerlessness one has over alcohol and that one’s life has become unmanageable.

PowerlessnessFacilitate group discussion on topic of powerlessness. Discuss why people typically struggle against powerlessness. Feeling out of control over the events in one’s life is in contrast to what we have been socialized to and gives the sense of vulnerability. Identify what people are typically making attempts to control (for example: other people’s behavior, internal events). Discuss success of these attempts and workability of such attempts. This discussion is helpful for setting up the idea of using the Serenity Prayer to identify what is under one’s control and what one is powerless over. Ask a group participant to say the serenity prayer out loud to the group.

Control As The ProblemWrite a chart on a dry erase board with two headings: “What You Are Powerless Over” and “What you Have Control Over” (See page 20). Ask for examples from group participants about control strategies. This includes a long list of specific external and internal events, such as other people, negative consequences, cravings to use and injustice. The final chart should reflect the idea that the only thing anyone has control

20

over is his or her values, attitudes and actions in this moment (make explicit this does not include events in the past or future).

What You Are Powerless Over(No Choice)

What You Have Control Over(Choice)

Other people’s thoughts, feelings, attitudes, and actions in the past, present, and futureYour own thoughts and feelings in the past, present, and futureYour values, attitudes and actions in the past and Future

Your values, attitudes and actions right this moment

Pose the question to the group: “What if it is the case that control and/or avoidance is the problem – not the solution – at least in some cases?” Facilitate group discussion to differentiate when control and avoidance does work (for example, running from a tiger or getting out of a house when there is a fire) versus when it does not work (for example, trying to control other people, using substances to block out negative memories).

Next, ask for a volunteer from the group to participate in acting out a metaphor with the group leaders, the Tug-a-War-with-a-Monster Demonstration.

Tug of War With A Monster“The situation is like being in a tug-of-war with a monster. It is big, ugly, and very strong. In between you and the monster is a pit, and so far as you can tell it is bottomless. If you lose this tug-of-war you will fall into this pit and will be destroyed. So you pull and pull, but the harder you pull it seems the harder the monster pulls, and it seems you edge closer and closer to the pit. The hardest thing to see is that our job here is not to win the tug-of-war. ..... Our job is to drop the rope.”

Facilitate group discussion regarding the alternative to struggling with the monster and attempts at control, which is to let go of the rope (struggle). Allow group members to come to the understanding that the monster will remain on the other side of the pit, remaining scary and ugly. However, the advantage to dropping the rope and looking at the monster for what he is is that the patient has the freedom to move around. This allows the patient to see the monster from different vantage points and frees he or she up for new possibilities and actions. The patient has to be willing to accept the discomfort of seeing the monster across the pit before he or she can gain this freedom.

Clean Versus Dirty DiscomfortDistinguish between “clean” and “dirty” discomfort. The discomfort that life just dishes up--that comes and goes as a result of just living one’s life--that is “clean” discomfort. Sometimes it will be high, or it will be low, because of individual learning histories and the environmental circumstances in which patients find themselves. The “clean” discomfort is what can’t be decreased by trying to control it. “Dirty” discomfort, on the other hand, is emotional discomfort and disturbing thoughts actually created by your effort to control feelings. As a result of running away, whole new sets of bad feelings

21

have shown up. Allow patients to connect with the idea that this process is a part of why they are in treatment. That extra discomfort--discomfort over discomfort--is called “dirty discomfort.” Once willingness is high, and control is low, it kind of falls out of the picture, leaving only the “clean” kind. Discuss the fact that one can never predict the level of discomfort he or she will have left in any given situation once only “clean” discomfort is there. Be very clear with group members that the idea is not that discomfort will go down, but that if efforts to manipulate discomfort is let go of, then over time it will assume the level that is dictated by patients’ actual history and experience.

What Acceptance is NOTPatients often hear acceptance and think “resignation.” Allow patients to discuss their thoughts on the word acceptance and distinguish between active acceptance and passive resignation. Acceptance is not the same as “giving up.” Acceptance is an active process of feeling what you feel, thinking what you think, remembering what you remember. It involves the willingness to let your experience be exactly what it is. Use AA slogan of accepting “life on life’s terms” to illustrate this idea, which many patients often connect to.

HomeworkHand out homework assignment and explain rationale.

22


Homework Assignment

Control and Willingness

1. Identify a situation, person, or event that you have had difficulty accepting.

2. What thoughts do you have about this situation, person, or event?

3. What emotional reactions come up for you when you think about this situation, person, or event?

4. Who would you be IF you were able to accept this situation, person, or event exactly as it is? How would you be different? How would your life be different?

23



HEAVEN AND HELL

There’s another story that you may have read that has to do with what we call heaven and hell, life and death, good and bad. It’s a story about how those things don’t really exist except as a creation of our own minds. It goes like this: A big burly samurai comes to the wise man and says, “Tell me the nature of heaven and hell.” And the roshi looks him in the face and says: “Why should I tell a scruffy, disgusting, miserable slob like you?” The samurai starts to get purple in the face, his hair starts to stand up, but the roshi won’t stop. He keeps saying, “A miserable worm like you, do you think I should tell you anything?” Consumed by rage, the samurai draws his sword and he’s just about to cut off the head of the roshi. The roshi says, “That’s hell.” The samurai, who is in fact a sensitive person, instantly gets it, that he just created his own hell; he was deep in hell. It was black and hot, filled with hatred, self-protection, anger, and resentment, so much so that he was going to kill this man. Tears fill his eyes and he starts to cry and he puts his palms together and the roshi says, “That’s heaven.”

There isn’t any hell or heaven except for how we relate to our world. Hell is just resistance to life. When you want to say no to the situation you’re in, it’s fine to say no, but when you build up a big case to the point where you’re so convinced that you would draw your sword and cut off someone’s head, that kind of resistance to life is hell.

In the way we practice, we don’t say, “Hell is bad and heaven is good” or “Get rid of hell and just seek heaven,” but we encourage ourselves to develop an open heart and an open mind to heaven, to hell, to everything. Why? Because only then can be realize that no matter what comes along, we’re always standing at the center of the work in the middle of sacred space, and everything that comes into that circle and exists with us there has come to teach us what we need to know.

Life’s work is to wake up, to let the things that enter into the circle wake you up rather than put you to sleep. The only way to do this is to open, be curious, and develop some sense of sympathy for everything that comes along, to get to know its nature and let it teach you what it will. It’s going to stick around until you learn your lesson at any rate. You can leave your marriage, you can quit your job, you can only go where people are going to praise you, you can manipulate your world until you’re blue in the face to try to make it always smooth, but the same old demons will always come up until finally you have learned your lesson, the lesson they came to teach you. Then those same demons will appear as friendly, warmhearted companions on the path.

Pema ChodronThe Wisdom of No Escape and the Path of Loving-kindnesspp. 31-32

24



Review of Control as the ProblemFirst, ask patients for reflections or thoughts on Wednesday Quiet Reflection. Ask if anyone can connect the Quiet Reflection to the week’s theme of Willingness. Review with patients the rationale for Control as the Problem. Ask group members to remember some of the main control strategies they had identified in Monday group and the main theme that connects them – control. Review table created on Monday (Powerlessness v. Control). Finally briefly summarize the distinction between clean and dirty discomfort.

The Cost of UnwillingnessAs patients if they can identify any costs of being unwilling to experience their thoughts and feelings. Generate a list of negative consequences of experiential avoidance. This may include a long list of things such as social isolation, poor relationships, loss of employment, etc. Keep in mind ten values areas while helping patients think of consequences. Relate some basic ideas to group such as: If you’re not willing to have it, you’re stuck with it.

MetaphorsTwo Scales Group leaders physically create the two scales with paper anchors (Likert-scale numbers written on large pieces of paper) in the middle of the group of patients. Ask for a volunteer to physically move one group leader up and down on the scale while the other group leader explains the metaphor. Have them both stand with the Discomfort scale in front of them and the Willingness Scale behind them. Explain the numbers are anchors on are two scales, like the volume. It can go from 0 to 10. In the posture you’re in, what brought you in here, was this: “This discomfort is too high.” It’s way up here and I want it down here and I want you, the therapist, to help me do that, please. In other words you have been trying to pull the pointer down on this scale (The group participant pulls the group leader down to 0, while the group leader resists against him or her). But now there’s also another scale. It’s been hidden. It is hard to see. This other scale can also go from 0 to 10. [move the other hand up and down behind your head so you can’t see it] What we have been doing is gradually preparing the way so that we can see this other scale. We’ve been bringing it around to look at it. [move the other hand around in front] It is really the more important of the two, because it is this one that makes the difference and it is the only one that you can control. This second scale is called “Willingness.” It refers to how open you are to experiencing your own experience when you experience it--without trying to manipulate it, avoid it, escape it, change it, and so on. When Discomfort is up here at 10 (Group leader stands at 10 anchor), and you’re trying hard to control this discomfort, make it go down, make it go away (Have group participant try to move other leader down to 0 on Willingness Scale), then you’re unwilling to feel this discomfort. In other words, the Willingness scale is down at 0. But that is a terrible combination. It’s like a ratchet or something. You know how a ratchet wrench works? When you have a ratchet set one way no matter how you turn the handle on the wrench it can only tighten

25

the bolt (Act this out dramatically on the scales with group leaders and patient). It’s like that. When Discomfort is high and Willingness is low, the ratchet is in and Discomfort can’t go down. That’s because if you are really, really unwilling to have Discomfort then it is something to be anxious about. It’s as if when Discomfort is high, and Willingness drops down, the discomfort kind of locks into place. You turn the ratchet and no matter what you do with that tool, it drives it in tighter. So, what we need to do in this therapy is shift our focus from the Discomfort scale to the Willingness scale. You’ve been trying to control Mr. Discomfort for a long time, and it just doesn’t work. It’s not that you weren’t clever enough; it simply doesn’t work. Instead of doing that we will turn our focus to the Willingness scale. Unlike the Discomfort scale, which you can’t move around at will, the Willingness scale is something you can set anywhere. It is not a reaction--not a feeling or a thought--it is a choice. You’ve had it set low. You came in here with in set low--in fact coming in here at all may initially have been a reflection of its low setting. What we need to do is get it set high. If you do this, if you set Willingness high, I can guarantee you what will happen to discomfort. I’ll tell you exactly what will happen and you can hold me to this as a solemn promise. If you stop trying to control discomfort, it will be low ... or ... it will be high. I promise you! Swear. Hold me to it. And when it is low, it will be low, until it’s not low and then it will be high. And when it is high it will be high until it isn’t high anymore. Then it will be low again. ... I’m not teasing you. There just aren’t good words for what it is like to have the Willingness scale set high--these strange words are as close as I can get. I can say one thing for sure though and your experience says the same thing--if you want to know for sure where the anxiety scale will be then there is something you can do. Just set Willingness very, very low and sooner or later when anxiety starts up the ratchet will lock in and you will have plenty of anxiety. It will be very predictable. All in the name of getting it low. If you move the Willingness scale up then anxiety is free to move. Sometimes it will be low, and sometimes it will be high, and in both cases you will keep out of a useless and traumatic struggle that can only lead in one direction.

Box Full of Stuff Before beginning this metaphor, group leaders should gather a trash can and several small objects. Suppose we had this trash can here. This [put various small items in the box, some nice and some repulsive] is the content of you life. All your programming. There’s some useful stuff in here. But there’s also some old cigarette butts and trash in here. Now let’s say there are some things in here that are really yucky that you all have experienced, like divorce, traumatic experiences and chronic pain . That would be like this [blow your nose into a tissue and put it in the box]. Ask a group member what they would do with the bad memories (e.g., “I’d think of something else.”). When they give an answer that fits with a control strategy, pick up another item and place it in the trash can identifying it as that suppression method. Ask for more thoughts/feelings, placing them in the trash can one by one. Do you see what is happening? This box is getting pretty full and notice that at lot of these items have to do with that first yucky one. Notice that the first piece isn’t becoming less important--it’s becoming more and more important. Because your programming doesn’t work by subtraction so the more you try to subtract and item, the more you add new items about the old. Now it’s true, some of this stuff you can shove back in the corners and you can hardly see it anymore but it’s all in there. Stuffing things

26

back in the corners is seemingly a logical thing to do. We all do it. Problem is, since the box is you, at some level the box knows, is in contact with, literally up next to all the bad stuff you’ve stuffed in the corners. Now, if the stuff that’s in the corners is really bad, it’s really important that it not be seen. But that means that anything that is related to it can’t be seen, so it too has to go into the corner. So you have to avoid the situations that will cause light to be cast into the corners. Gradually your life is getting more and more squeezed. And note that doesn’t really change your programming--it just adds to it. You’re just stuffing another thing back into the corner. There becomes more and more things you can’t do. Can you see the cost? It must distort your life. Now the point is not that you need to deliberately pull all the stuff out of the corner--the point is that healthy living will naturally pull some things out of the corner and you have the choice either to pull back to avoid it or let going forward with life open it up.”

HomeworkHand out Journal Group Assignment.

27



“Pain is inevitable; suffering is optional.”

This week we are discussing how we tend to make our problems worse and increase our suffering by refusing to accept reality as it is RIGHT NOW, and by our unwillingness to experience whatever thoughts, feelings, memories, and physical sensations accompany that reality. We call this “dirty discomfort.” In the story of the Samurai, the wise man taught him how he had created his own “hell” by his unwillingness to accept the situation for what it was.

1. How do you create “dirty discomfort” for yourself? How do you take a stressful situation and make it worse? In your journal entry, please write about something that happened today in which your unwillingness to accept the reality of the situation ended up making things WORSE for you!

2. Next, write about a situation that happened today in which your willingness to accept the situation as it was, and your willingness to “own” your feelings, thoughts, and reactions to the situation, brought you at least a little taste of peacefulness and calm…

28



A. CONTROL AND AVOIDANCEOR

B. ACCEPTANCE AND WILLINGNESS

Identify the approach (A or B) that best fits each of the statements below:

____ When negative experiences occur, the goal is to get rid of them or get them under control so that they hurt less.”

____ The attempt to control or get rid of negative experiences creates problems; the goal is to let them be there, and they will change as a natural part of living.

____ The way to understand negative experiences is to understand why I am having them, and then use that knowledge to eliminate them.

____ The way to understand negative experiences is to notice that they are present without necessarily analyzing them or judging them.

29

Week Three: Defusion/Deliterization


Defusion Reflection

"Do we control what we think?"

Facilitate debate of this topic for 10 minutes

Reflection Question: What would it mean if we do control our thoughts and what would it mean if we don't actually control our thoughts?

30


Monday Curriculum

Review of Control as the Problem and Willingness:First, ask patients for reflections or thoughts on Monday Quiet Reflection. Briefly review the concepts and rationale for Control as the Problem and Willingness.

Pop QuizHand out the pop quiz below. Group leaders typically use irreverent humor to indicate the importance of getting each question “right” by stating the quiz will be graded, or saying that their grade will determine their progress or be judged harshly.

Note: These comments should be used in a light and playful manner, as some patients may fear unsuccessful completion in the treatment program. If group leaders note distress or fear in patients when this is stated, misconceptions should quickly be corrected. If after several attempts at using this style, it appears the patients do not respond well, other approaches to introducing psychological flexibility are encouraged.

Allow group approximately ten minutes to complete the quiz, then facilitate discussion of answers one by one. Group leaders should play the devil’s advocate on both sides of each question by using the key discussion points and exercises listed below each question. The point of this group exercise is not to decide on an answer to each question, but to encourage flexibility in thought by recognizing there may be no right answer.

RECOVERY POP-QUIZAcceptance and Willingness, Part II

1. I think, therefore I am T F

Discussion Points: Each individual has a learning history that includes being taught that thinking is

equivalent to being. Identify instances where this idea can be true (How do we know if we are living if we don’t have a consciousness?) and also instances where this is untrue (e.g. comatose states).

Defusion exercises: Encourage patient to try replacing the thought “I am depressed” with.” I am

having the thought that I am depressed.” Put thought on the board and stand back to look at it. What does it mean to be

able to "observe" one's own thought? How does this observer perspective change one’s contact with the thought? Can one observe a thought and still be a living, breathing human being at the same time?

2. If this program teaches me anything, T F it’s that avoidance is always unhealthy

31

Discussion Points: Rigid adherence to rules has typically not worked for people in the past.

Facilitate discussion on instances where rule governed behavior has gotten them into problematic patterns of living.

Stress the functional/contextual nature of avoidance, reminding patients examples from previous week in Willingness.

There are some things we simply cannot avoid, such as internal states (thoughts). Again, stress the need to determine the workability of avoidance, particularly with internal states. Identify times where group members made efforts to avoid painful thoughts or memories by using substances or other methods and this effort caused increased psychological distress.

3. The more I try to stop a thought, the stronger the thought becomes T F

Defusion Exercise:Instruct patients to not think of chocolate cake for 30 seconds. “Suppose I tell you right now, I don’t want you to think about something. I’m going to tell you real soon. And when I do don’t think it even for a second. Here it comes. Remember, don’t think of it. Don’t think of ....Warm chocolate cake! You know how it smells when it first comes out of the oven...Don’t think of it! The taste of the chocolate icing when you bite into the first warm piece ...Don’t think of it! As the warm, moist piece crumbles and crumbs fall to the plate...Don’t think of it! It’s very important, don’t think about any of this!”

Discussion Points: Facilitate discussion after the exercise on the futility of thought suppression

following this experience. Ask patient how often they thought of chocolate cake prior to this exercise and

compare this with how many times an intrusion of chocolate cake occurred in the past 30 seconds.

Highlight how many associated thoughts come up when one tries to suppress thoughts (e.g., thoughts of milk, birthdays, etc.) as well as bodily sensations (e.g., stomach growling, salivation, etc). Relate this to cravings and related thoughts, sensations, memories, etc.

4. In recovery, behaviors must change T F but my thoughts and feelings are OK the way they are.

Defucsion Exercise: Soldiers on Parade: If you are willing, I’d like to do a closed eyes exercise to

show how quickly thoughts can pull us away from experience when we buy them. All I’m going to ask you to do is think whatever thoughts you think and to allow them to slow, one thought after another. The purpose of the exercise is to notice

32

when there’s a shift from looking at your thoughts to looking from your thoughts. You will know that has happened when the parade stops, or you are down in the parade, or the exercise has disappeared. I’m going to ask you to imagine that there are little people, soldiers, marching out of your left ear down in front of ou in a parade. You are up on the reviewing stand, watching the parade go by. Each soldier is carrying a sign, and each thought you have is a sentence written on one of these signs. Some people have a hard time putting thoughts into words, and they see thoughts as images. If that applies to you, put each image on a sign being carried by a soldier. Simply watch the parade go by without having it stop and without your jumping down into the parade. You are just supposed to let it flow. It is very unlikely that you will be able to do this without interruption. And this is the key part of this exercise. At some point, you will have the sense that te parade has stopped, or that you have lost the being point of the exercise, or that you are down in the parade instead of being on the reviewing stand. When that happens, I would like you to back up a few seconds and see whether you can catch what your thoughts on the placards again, until the parade stops a second time, and so on. The main thing is to notice when it stops for any reason and see whether you can catch what happened right before it stopped. If the parade never gets going at all and you start thinking, “It’s not working,” or “I’m not doing it right,” then let that thought be written on a placard and send it down into the parade.

Discussion Points: Adopting a stance of acceptance and mindfulness of thoughts allows use to slow

down habitual ways of responding to triggers and choose our behaviors more carefully.

Homework Assignment Hand out homework assignment and answer any questions patients have about completing it.

33


Homework Assignment

Reacting to Uncomfortable Emotions:

AVOIDANCEStuffing It------------------------------------------------------------------------Acting It Out

Responding to Uncomfortable Emotions:

EXPERIENCING IT"Sitting with it"

List two emotions that you wish you could get rid of.________________________________________________________________________________________________________________________________________________

How have you tried to avoid/get rid of each of the two emotions you listed?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How has trying to get rid of these emotions gotten in the way of living a valued life?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

34

Week Three: Defusion/Deliterizaton


The Squiggly Line Exercise

On the board, make a few non-descript squiggles with an ink marker.Ask patients what they see…Notice the tendency to read into, project, or otherwise interpret something when nothing is actually there but ink on a board.Tell patients that all that is there is a bunch of squiggly lines made out of ink.

Now write up on the board the words: "You are all wimps"Ask patients what they see…Ask what feelings and thoughts come upRemind patients that all that is on the board is more squiggly lines made out of ink.

Now just change the letters slightly to make the words read: "You are all winners"Ask patients what they now see…Ask what feelings and thoughts come up now.Remind patients that all that is on the board is differently shaped squiggly line made out of ink.

The message of this exercise is that our thoughts are like squiggly lines—they come and go and change all the time, sometimes they seem to mean something, sometimes not. Our job is simply to notice them and notice if we are feeding into them and remind ourselves: that is just a thought (that is just a squiggly line – this is just ink).

35



Review of Control as the Problem and Willingness:First, ask patients for reflections or thoughts on Wednesday Quiet Reflection. Review concepts from Monday curriculum. Relate psychological flexibility taught in Monday curriculum to Wednesday Quiet Reflection. Discuss idea of thoughts being ink/words that humans attach meaning to. Have patient been able to notice thoughts from this detached perspective over the course of the day? Identification of ThoughtsGroup leaders should come prepared with paper, pens and a trash can.

Hand out a sheet of paper to group members and ask them to write down a commonly occurring uncomfortable thought. Reinforce to patient this should be a “bad” thought, or a negative thought they have been trying hard to get rid of. When everyone has identified a thought, ask patients to crumple up their papers. One group leader will collect their “bad thoughts” in the Bad Thought Wastebasket.

The co-facilitator will sit in a chair in the middle of the circle for the defusion exercise.

Getting Rid of the Bad Thoughts “We are going to practice getting rid of bad thoughts. We are going to practice using your thoughts. The group leader’s job is to keep all these thoughts from hitting him.”

Group leader will throw the balled up paper at him, slowly, then faster, varying the throws. The co-facilitator tries urgently to block all the paper, using a lot of energy and activity.

Ask participants what they noticed about this exercise. Some questions to get them thinking about the frequency and intensity of thoughts are:

“Did you notice how some thoughts come in slow and easy, and others are fast and racing?”

“Did the pace or strength change according to how much the group leader struggled not to have them?”

Facilitate discussion about the utility of thought suppression in this exercise. “So how did the group leader do?” “How hard was he working? “How much energy was he using to block out all those thoughts? “How successful was he? “How much energy did he have for doing anything else?

Meditation-Getting Rid of the Bad Thoughts

36

“I want you all now to practice this like the group leader did, except we’ll use real thoughts instead of paper. I want everyone to sit in a comfortable, upright position, keeping your eyes OPEN. I want you to remember the BAD thought you wrote down and hold it in your mind. When you’ve got that thought in your mind, please raise your hand. Now, what I want you to do is concentrate very hard, keep your eyes open, and for the next two minutes, I want you to get rid of that thought. Go ahead.”

Facilitate discussion of their own experiences with attempts at thought suppression. “How did you do? “How much mental energy did you use to block out all those thoughts? “How successful were you? “How much energy did you have to do other things?

Holding on to Good ThoughtsHand out a sheet of paper to group members and ask them to write down a happy, pleasant, positive thought. Reinforce to patient this should be a “good” thought, or a thought they have been really wish to have more often. When everyone has identified a thought, ask patients to crumple up their papers. One group leader will collect their “good thoughts” in the Good Thought Wastebasket.

“Now we are going to practice holding onto pleasant thoughts. So to begin, I want everyone to ball up their piece of paper. Now I want everyone to throw their 'good’ thought into this wastebasket”.

The co-facilitator will sit in a chair in the middle of the circle for the defusion exercise.

“We are now going to practice holding onto good thoughts. We are going to practice with your thoughts. The group leader’s job this time is to catch and hold onto all of these thoughts and not to drop any of them.”

The group leader will throw the balled up paper at him, slowly, then faster, varying the throws. The co-facilitator will try urgently to catch and hold onto all the paper, using much energy.

Ask participants what they noticed about this exercise. Some questions to get them thinking about the frequency and intensity of thoughts are:

“Did you notice how some thoughts come in slow and easy, and others are fast and racing?”

Facilitate discussion about the futility of trying to increase positive thoughts. “So how did the group leader do?” “How hard was he working? “How much energy was he using to block out all those thoughts? “How successful was he? “How much energy did he have to do other things?

37

Meditation-Holding on to the Good “I want you all now to practice this like the group leader did, except we’ll use real thoughts instead of paper. I want everyone to sit in a comfortable, upright position, keeping your eyes OPEN. I want you to remember the thought you wrote down and hold it in your mind. When you’ve got that thought in your mind, please raise your hand. Now, what I want you to do, is concentrate very hard, keep your eyes open, and for the next two minutes, I want you to keep that thought in your head. Don't allow the thought to leave your mind, even for a second, or allow any other thought in. Go ahead.”

Facilitate discussion of their own experiences with trying to increase positive thoughts. “How did you do? “How much mental energy did you use to block out all those thoughts? “How successful were you? “How much energy did you have to do other things?

Having the Thoughts The co-facilitator will sit in chair in middle of the room again. This time, he is instructed to simply “have the thoughts.” Paper is thrown at him in a similar way, but this time, the group leader does not attempt to block them away. He lets them hit him and bounce off.

Ask participants what they noticed about this exercise, noting differences between the first two exercises is particularly important. Allow patients to identify similarities and differences on their own before using leading questions.

“So how did the group leader do this time?” “Did the frequency of intensity of thoughts change from the other two exercises?” “How hard was he working? “How much energy was he using to block out all those thoughts? “How successful was he? “How much energy did James have to do other things?

Experiential Exercise: Clouds in the Sky“I want you all now to practice this like the group leader did, except we’ll use real thoughts instead of paper. I want everyone to sit in a comfortable, upright position, keeping your eyes OPEN. I want you to remember the thought you wrote down and hold it in your mind. When you’ve got that thought in your mind, please raise your hand. Now, what I want you to do, is follow along with the meditation.

Do you remember how as a kid it was fun to lie on the ground and look up at the clouds moving across the sky? Sometimes you saw shapes in the clouds, and maybe you even saw pictures or things happening. Sometimes the sky is empty of clouds, but usually there are at least some clouds. Often, the sky is filled with big clouds, sometimes, it’s overcast, dark, and rainy. Sometimes the clouds don’t appear to move much at all, and sometimes, when it’s windy, the clouds move very quickly across the sky.

Watching our own thoughts is like looking at clouds move across the sky.

38

I want you now to picture the thought that you wrote down and imagine as if you are actually seeing the letters of the words to that thought appear in your mind like they are clouds in the sky. Make no effort to get rid of the letters. Just look at them. Notice their color, shape, size, movement. What happens when you make no attempt to get rid of the letters and words? What would it be like to try to reach into the sky and push a cloud more quickly through the sky. Would it work? As you allow yourself to have the thought, now see if any other thoughts float through your mind. What is it like to not fight with them?”

Facilitate discussion of their own experiences during the exercise. “How did you do? “How much mental energy did you use to block out all those thoughts? “How successful were you? “How much energy did you have to do other things?

Journal Group AssignmentHand out journal group assignment and answer questions patient may have about completing it.

39



Take Your Keys With You…

For your journal group assignment this week, identify several different emotions, thoughts, memories, or sensations you have been struggling with lately. These can be about trauma, substance abuse, or both.

Examples include:

“I don’t think I can ever stop using.” “I will never make up all my years of using to my family.” Tightness in chest, restlessness, or other sensations of anxiety and cravings Memories of your trauma

Write your own examples here:

1. _______________________________________________________

2.________________________________________________________

3. _______________________________________________________

Now, take 3 small pieces of paper. Write your examples on the papers. Then, tape the papers to 3 keys on your key ring. If you are willing, your homework is to carry your keys, and your thoughts, memories, feelings, and sensations, with you for the next week.

Journal about several things during the next week about your experience carrying your keys:

How much effort does it take to carry your keys with you?

What places can you go, or not go, depending on whether you have your keys with you?

Does picking up your keys and carrying them with you prevent your from going anywhere?

40



Cravings News Radio Metaphor

CRAVINGS NEWS RADIO (WSNR): “This is Cravings News Radio, WSNR, broadcasting inside your head, twenty hours a day, seven days a week. Wherever you are, the signal will reach you. When you wake in the early hours, we’ll be there to make you aware of your craving to smoke, even before you get out of bed. Let us take over and control your life. Cravings News Radio is compelling listening, and guess why? It’s the news station you’ve lived with for years, and now comes to you automatically, 24/7. Pay attention! Cravings News Radio knows what’s best for you and we want you to buy our products. We advertise the products you fear most and want to avoid. So don’t forget that, and remember, if you should forget us and ACT without seeking permission, then we’ll broadcast all the louder. Remember, having cravings can be really awful, so you should stay tuned to this station to know how to avoid them.”

JUST SO RADIO (WJSR): “Wake up! Cravings News Radio is just a station – you can tune in, or you can tune out! One thing is guaranteed though, whatever the time of day, you’ll hear the same old stuff on WSNR. If that’s been really helpful to you, then go ahead, tune in and stay tuned. That would make sense. If not, then tune in more often to Just So radio. We bring you the news of actual experience, in the moment, all live, all the time. Actuality is out business! We give it to you straight – as it is, not as your mind says it is. In contact with the world outside and inside the skin, you can experience what it is to be human, and it’s entirely free! We can guarantee that experiencing what’s inside the skin – exactly as it is – will never damage you, but it just might bring you joy. Just So Radio brings you information about how things are, not how you fear they might be. Just So Radio invites you to step forward and touch the world, just as it is, and to touch your life, just as it is. We get louder the more you listen to us. So stay tuned. Give us a fair trial, and if not convinced by your own experience (please don’t take our word for it) then WSNR 9 Cravings News Radio – is still there on the dial.”

41

Week Four: Values


Values ReflectionsA little over ten years ago, as I was beginning my journey to integrating sacred pampering and self-care into my life, I thought that having more joy and deep satisfaction in my life was a matter of “getting my priorities straight.” A priority is something we regard as more important than something else. But I discovered that having more joy in my life didn’t come about as a result of getting my priorities straight, but from having my actions and behaviors consistent with what I said I valued. What you value is what you consider significant and important.

An assessment of where, how, when, and with whom we invest our time and energy is an accurate and telling barometer for where our priorities lie. We think that we act in accordance with what we value. This is usually not the case. Most of us are usually doing the opposite—our actions and behaviors are supporting something very different from what we say is important to us. Unfortunately, this is the norm.

When your behavior is at odds with what you value, you experience anxiety, dissatisfaction, “spiritual constipation,” and internal conflict. These are by-products of the head-on collision of our behaviors and our values. What you value is a function of your beliefs. Someone’s values, and thus his or her beliefs, show through a person’s actions, behaviors, and choices. In other words, demonstration is the vehicle through which our values are revealed. When you say your values are one thing yet your actions and behaviors demonstrate another, you undermine your power, integrity, and spiritual energy.

Debrena Jackson Gandy, from All The Joy You Can Stand

You don’t get to choose how you’re going to die. Or when. You can only decide how you’re going to live. Now.

Joan Baez

He who is not courageous enough to take risks will accomplish nothing in life. Muhammed Ali

42

Week Four: Values Monday Curriculum

Group leaders will need a dry erase board, markers, 3x5 cards and pens for the group.

Review of ACT Rationale Briefly review Control as the Problem, Willingness and Defusion concepts from previous weeks for new members. Ask participants for thoughts on Monday Quiet Reflection, relating this to themes discussed in previous weeks. Write the quote “If we don’t decide where we’re going, we’re bound to end up where we’re heading” on the board to start off the lecture. Ask for the participants’ reactions to this statement.

Values and GoalsReview the definitions of values and goals by asking the group to list the characteristics of each & write them on the board.

Values –a direction; a quality action.1.) verbally construed global desired outcomes2.) cannot be permanently achieved & maintained3.) gives direction4.) an action-“valuing”-not a private thought

Values are sometimes confused with feelings. Feelings & thoughts come & go; values are bigger-give life meaning & direction. Goals are something you choose to work at; they are time-oriented, specific, & measurable. They are proud to accomplish. Ask group members how they view the relationship between values and goals.

Identification of a Value and GoalAsk participants to identify a value and specific goals related to it. Discuss poor examples of values/goals, such as the absence of something (e.g., not feeling anxiety). Striving for the absence of something often is a poor guide and can lead to avoidance with long term use.

Discussion question: Is recovery a goal or a value? Discuss differences between a value and goal using recovery as an example.

Barriers Ask participants what are some barriers that get in the way of living according to one’s values? Get specific examples from group members of practical barriers, such as financial concerns, transportation and poor social support. Then ask about other internal barriers, such as thoughts, emotions, our past experiences, our bodily states, our “head chatter.” Allow group discussion of how these internal events get in the way of achieving goals and moving toward our values.

43

Choosing Value ExerciseIdentify a value on the board, like “meaningful relationships with family”. During recovery, many people want to reconnect with family but have fears in doing so. Have 3x5 cards and pens ready.

Write the value “Family” on the dry erase board. Ask group participants to identify a thought/emotion that may get in the way of making an attempt to reach out to family. Have patients write down this thought or emotion on a 3x5 card. Some examples of common thoughts related to family include:

I’m afraid they’ll reject me. I’m afraid they will judge me and say I’m no good. They’ll be angry with me.

Ask for five or six volunteers who are willing to share their thoughts that they wrote down. Ask each person to stand up in the center of the room with their card.

Ask them to line up and one by one, walk by the group leader as they read the barrier out loud. The group leader will be facing the dry erase board with the value written on it. As each patient reads their statement, the group leader will agree with it & expound on it. For example, saying “Yes, yes, you’re right, they should reject me, I’ve let them down for so long and have not been dependable.” With each statement, the group leader turns a little more away from facing the front (where the value is written on the board) toward the back as he becomes more and more engrossed with these thoughts & emotions. He is allowing himself to become distracted and pulled away from the value. Allow for discussion about what patients observed about this process.

Ask patients to line up again and repeat the exercise. This time, the group leader will face the front looking at the value. This time, as they read each statement, he will argue with it. For example, saying “No they won’t reject me, I’m doing well now; at least I’m in recovery.” Again, as he argues, the group leader gets distracted by having to defend against the thoughts and eventually turns away from the value. Allow for discussion about what patients observed about this process.

Ask patients to line up again and repeat the exercise one last time. This time, the group leader will face the value on the board & let each person walk by without responding… just watch them go by. .

Finally, the group leader will face the value on the board again. Ask each patient to get behind the group leader and place their hands on the leader’s shoulders. Ask them to continuously read their statements in unison while the group leader slowly moves toward the value on the board. Note: More than likely, as everyone moves toward the board, their voices get louder & louder.Briefly summarize the main points observed over the four parts of the exercise. “So what people noticed is in the second part was that I stood up to my thoughts and this is positive, not like in the first part, when I gave in to what my head was saying. Yes, that

44

may be true, but isn’t it like our minds to argue and give in to our thoughts? When we respond to our thoughts & emotions, we get caught up in them & lose contact with our value - we get distracted. In both the first and second part, I got caught up and turned away from the value. The third time, I did not fight with my thoughts and emotions; I let them be. Then, I chose to go toward the value even though I have these thoughts & emotions; I just took them with me. The head chatter may have gotten louder as I got closer to the value, but isn’t that just how our minds work a lot of the time?”

Process Versus OutcomeWrite the following sentence on the dry erase board.

“Outcome is the process through which process becomes the outcome.”

The Skiing Metaphor “Suppose you and I went skiing together and, feeling rather daring, we decided to do extreme skiing. You know, you are flown by helicopter to the summit of a tall peak and you ski your way straight downhill over crevasses, and glaciers. The challenge is to somehow confront all these unpredictable obstacles and show up alive at the lodge. Now the big day has arrived and as we’re getting on board the helicopter, you notice I have not brought my skis, poles, parka and so forth. You ask me why I don’t have my stuff with me. My response is, “Isn’t the objective to get from the summit down to the lodge? I thought that’s what we were coming here for. The easiest way I know to do that is to have them fly us up to the top and then fly us back down to the lodge.” I point out that flying up and down achieves exactly what flying up and skiing down achieves: Both have me starting at the top and ending up at the lodge alive. And besides, one has me getting cold, wet tired, thirsty, hungry and so on. The other has none of those discomforts and so obviously is the best way to go. There is only one problem: we came here to ski, not ride in helicopters. Skiing is not just the goal of getting to the lodge because any number of activities can accomplish that for us. Skiing is how we are going to get there. Getting to the lodge is important because it allows us to do the process of skiing in a direction. If I tried to ski uphill instead of down it wouldn’t work, so valuing down over up is necessary. Outcome is the process through which the process can be the outcome. Valuing getting down as a goal is the process through which we can reach our real goal: to ski.”

Facilitate group discussion about the problems of being too outcome focused—no vitality, oppressive; always operating from a state of deprivation. Goals create motivation & action, but solely focusing on them prevents us from experiencing NOW.

Homework AssignmentHand out homework assignment and answer any questions about completing it.

45

Week Four: Values

Monday Homework Assignment

“When the process of living becomes the outcome of interest, we are no longer living in a world of deprivation.”

How am I practicing living fully today?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What are some goals that are consistent with my values that can help me move forward this week?

1. __________________________________________________________________2. __________________________________________________________________3. __________________________________________________________________

46

Week Four: Values


Values Reflection

FROM: You can't stop the waves but you can learn to surfJon Kabat-ZinnWherever you go there you are, pp 30-31.

People who come [here] quickly learn that stress is an inevitable part of life. While it is true that we can learn, by making intelligent choices, not to make things worse for ourselves in certain ways. There are so many things over which we have little or no control. Stress is part of life, part of being human, intrinsic to the human condition itself. But is does not mean that we have to be victims in the face of large forces in our lives. We can learn to work with them, understand them, find meaning in them, make critical choices, and use their energies to grow in strength, wisdom, and compassion….

One way to envision how [this] works is to think of your mind as the surface of a lake or of the ocean. There are always waves on the water. Sometimes they are big, sometimes they are small, and sometimes they are almost imperceptible. The water's waves are churned up by winds, which come and go and vary in direction and intensity, just as do the winds of stress and change in our lives, which stir up waves in our minds.

47

Week Four: Values


Group leaders need a copy of the original ACT book and pens for the group.

Review of ValuesReview Monday curriculum and how values are related to ACT model. Discussion of why values are an important part of treatment.

Write definitions of value and goals on the dry erase board. Values are chosen life directions. Goals are actions that you can measure, can achieve. They help us move toward

our values.

Discussion Points How are they different? How are they similar? What are some examples of values and goals? What happens when values are out of line with our behavior? What is the relationship of having goals and barriers? [By the very nature of

setting goals, one will encounter barriers. Without goals, there are not barriers.]

Compass Metaphor“Values can be thought of as a setting a compass toward a meaningful life for each individual. Take the example of the wish to move west. If I were to leave Baltimore and head west, I’d arrive at Frederick, right? So would that be the end of heading west or not? So the idea you get from this is that going to Frederick might be a goal of mine, since it is west of here. But it wouldn’t be the end point; it would be just a point along my path of heading west.”

The Path Up The Mountain Metaphor Group Leader Note: This metaphor can be employed to help the client understand the hazards of constantly monitoring immediate life outcomes rather than connecting with valuing as a process.“Suppose you are taking a hike in the mountains. You know how they construct mountain trails, especially if the slopes are steep. They wind back and forth; often they have “switchbacks” where you literally walk back and forth and sometimes they will even drop back down below a level you’ve already reached. If I asked you at any given point on the trail to evaluate how well you are accomplishing your goal of reaching the mountain top, I would hear a different story every time. If you were in switchback mode, you would probably tell me that things weren’t going well, that you were never going to reach the top. If you were in a stretch of open territory where you could see the mountain top and the path leading up toward it, you would probably tell me things were going very well. Now, imagine that we are across the valley looking at people hiking on this trail. If we were asked how they were doing, we would have a positive progress report every time. We would be able to see that the overall direction of the trail, not what it looks like

48

at a given moment, is the key to progress. We would see that following this crazy, windy trail is exactly what leads to the top”

Allow group discussion to reflect on this metaphor. Ask patients how the path up the mountain may be similar to their own journey of recovery and treatment. Ask if there have been times when it seemed like they may have been headed the wrong way, or seemed as if they were headed downhill when they were trying to move toward the top of the mountain. Elicit personal examples when patients are willing to do so. Ask patients for their thoughts on why their journey might look different to a person across the valley watching their progress? Finally, get ideas on how their perspectives may change as they move along the path.

Identification of Personal Values and Goal SettingRefer to Wednesday Journal Assignment (See page XX). Read the list of values to patients out loud, stating these are some common life areas that people typically think are important.“I’d like to read you a list of nine areas that people often feel at important: friendship, intimate relationships, family relationships, work, education, recreation, giving back to others or citizenship, spirituality, and physical health and well-being. We have been discussing how these are important to you this week. It may seem like all of these are important, or you may have one or two areas that seem most relevant to you. I’ll invite you to focus your attention in a few of these areas.

I’m going to read the list to you again, and then I want to ask you a question. Friendship, intimate relationships, family relationships, work, education, recreation, giving back to others or citizenship, spirituality, and physical health and well-being. If you were to imagine three things that you’d like for people to say about you after you die, what would those three things be?”

Hand out assignment to group members: Valued Areas of Life (See page XX). Ask patients to pair up with the person sitting next to them and work in pairs. Instruct patients that during this group, they will be asked to work on the first page with their partner. They will be asked to work on the back page as the journal group assignment for Thursday.

Ask patient to look at the list of Valued Areas of Life at the top of the page. Ask group participants to choose one of the listed values to work on with their partner in group for a few minutes. Make a general inquiry about participant's choices of which area they want to focus on and ask about what they would imagine doing. Redirect choices that contain fears, limitations, or reasons not to try.

Group leaders may choose to use a personal example to illustrate how to complete the exercise on the dry erase board.“I decided to choose education/training for my area. So I will write that in the space by 1a. does everyone see where to write it?

49

Now look at 1b. If I were to imagine what I'd like to be doing to increase my knowledge or skills, maybe I'd want to go to trade school or finish up a college degree. In 1b, I would write what I'd LIKE to do in education.” Ask patients for input for possible goals in the area of education that the group leader might use.

“Finally, look at area 1c. Please write down things that might get in the way of you achieving your goals. Sometimes, this would come from outside of you, like the need to focus on caring for family members or staying in treatment right now, rather than focus on attending class.

Can you think of external reasons that I might not be able to attend to my educational goals fully right now? What are some reasons on the INSIDE that I might not achieve what I imagine? I might be afraid to take a class because I'd fail, or I'd feel bad that I was a lot older than other people finishing a diploma.

Remember what we said about goals? It's absolutely certain that when we have goals, we'll have barriers-—some of them are outside of us, and some of them are from inside. Your job is to realize that barriers are a completely normal part of taking action, not something bad that's getting in the way. Having barriers means you're working toward something that is of importance.”

Ask group members to work with their partner for about ten minutes to complete the front page of the exercise together, one for each of person. Encourage active problem solving between each pair and specific goal setting. Remind patients of the aspects of a good goal (SMART goals: Specific, Measurable, Attainable, Realistic and Time-limited).

Review instructions with patients as they get started. “Write down your area here in the A part, then about what you would LIKE have happen here in part B. Remember, this is where you use your imagination. You'll probably have a lot of mental chatter about what will "get in the way of doing your goal". Your job is write what you dream of, what you hope for, and not worry about all the pitfalls. Now in area C, write down the pitfalls that you thought of.”

Allow patients approximately fifteen minutes to work together and then return to group format. Facilitate discussion on their experience with identifying specific goals. Ask for examples from patients about the areas they chose. Discuss what came up for people as they attempted to set goals, such as thoughts about barriers. Ask about their experience in identifying goals with a partner and if their partner helped them to stay on track when barriers came up.Provide general feedback and encouragement. Recognize when inner commentary gets in the way of setting a goal—that's something that can be acknowledged, but it need not stop the process of making a commitment to a goal. Suggest use of problem-solving skills, getting a second opinion, or acceptance for external barriers.

Journal Group AssignmentInstruct patients to continue working on the back page for their journal group assignment.

50

Week Four: Values


Please choose three areas (listed below). Then write about what you would like to be doing in that area. Finally, write some barriers to achieving these goals.

Valued Areas of Life

Intimate relationships FriendshipsFamily relationships Work/employmentEducation/training RecreationGiving back/Citizenship Spirituality

Physical health/Well-being

Example:1a. Education1b. Want to improve my education by pursuing my GED.1c. Need to focus on treatment and work right now.

1a. Area of Life: _____________________________

1b. What would you like to be doing in this area (list what you imagine, as if you could magically have whatever you want)?

1c. What are some reasons that you cannot move toward this valued direction? Please consider reasons both outside (people, places, things) and inside yourself (beliefs, thoughts, memories, feelings) that keep you from moving in this valued direction.

2a. Area of Life: _____________________________


51


3a. Area of Life: _____________________________



52

Week Four: Values


Gardening MetaphorImagine that you selected a spot to plant a garden. You worked the soil, planted the seeds, and waited for them to sprout. Meanwhile, you started noticing a spot just across the road, which also looked like a good spot—maybe even a better spot. So you pulled up your vegetables and went across the street and planted another garden there. Then you noticed another spot that looked even better. Values are like a spot where you plant a garden. You can grow some things very quickly, but other things require time and dedication. The question is, “Do you want to live on lettuce, or do you want to live on something more substantial—potatoes, beets, and the like?” You can’t find out how things work in gardens when you have to pull up stakes again and again. Of course, if you stay in the same spot, you’ll start to notice its imperfections. Maybe the ground isn’t quite as level as it looked when you started, or perhaps the water has to be carried for quite a distance. Some things you plant may seem to take forever to come up. It is at times like this that your mind will tell you, “you should have planted elsewhere,” “This will probably never work,” “It was stupid of you to think you could grow anything here,” and so on. The choice to garden here allows you to water and weed and hoe, even when these thoughts and feelings show up.

Reflection Question: What is your garden and what commitment can you make to it this week?

53

Week Five: Committed Action ( Just Do It )


Group leader will write “Just do it” on the dry erase board to begin Quiet Reflection.

Hitting a baseballThere are lots of books and videotapes instructing people how to hit baseballs. A person can read all the books, watch all the instructional videos, go to games, interview players, even swing the bat in their own backyard. But can a person actually hit a baseball by doing any of these things?

No.

What is the only way to hit a baseball?

Step up to the plate during a game and take a swing.

Discussion Points: We can talk, think, and plan as much as we want. None of that has any bearing

whatsoever on our everyday life until we change what we do. Substance abuse area is overflowing with sayings, clichés, aphorisms (give

examples), but none of them means anything—they are just words. Commitment is not to words but to actions. The commitment is to the effort, the

act itself, not to any consequences. Are you trying to move closer to aligning with your values?

This is not about “feeling good”; you may feel worse while you are aligning with your values. It is more about feeling “well.”

Reflection Questions: What can I change TODAY? What can I change THIS WEEKEND? What can I change NEXT WEEK? What can I change after that?

54

Week Five: Committed Action

Monday Curriculum

Group leaders will need a dry erase board, markers, handouts and pens for the group.

Review of ACT Rationale Briefly review Control as the Problem, Willingness, Defusion and Values concepts from previous weeks for new members. Ask participants for thoughts on Monday Quiet Reflection, relating this to themes discussed in previous weeks.

Definition of CommitmentReview the definitions of commitment by asking the group to list the characteristics of each & write them on the board.

Commit: to do, perform, or perpetrate; to bind or obligateCommitment: the state of being bound emotionally or intellectually to a course of action.

Differentiate between the word, what it means to patients and the implications of commitment. What place do words occupy in the process of making a commitment? Slogans and saying (e.g., One day at a time, Stick and stay) are often used to motivate people in recovery toward their commitments. However, words actually don’t factor into commitment at all. Facilitate discussion about what makes a commitment if words by themselves can not actually make a commitment. Guide group members toward the idea that commitment means actions.

OutcomesFacilitate group discussion on the distinction between making commitments and the outcomes of commitments. What is the relationship between the two? What does an outcome or an expected outcome have to do with the original intent to commit to a course of action? It most often has to do with our story of how we wish things will turn out. Relate this relationship back to the idea of willingness and power/control. Do we have any control over the actual outcome of our behaviors when we set out on a course of action? What matters is the ACT, not how it turns out. What matters is picking a course of action that is consistent with our values and making choices on that path each day.

Barriers to CommitmentGroup leader will write: “It would work in my life to do this, so therefore, I’m doing it.” Facilitate discussion on this statement. Although it seems easy and simple enough, many things get in our way when we think about making a commitment to a course of action. Relate this concept to the baseball metaphor from Monday Quiet Reflection. Ask group members to discuss why a person would do everything but get to the plate in a game and swing the bat? Write their answers on the dry erase board.

Many of the answers may revolve around a common theme of fear, or participants may give this answer directly. There are two types of fear: fear of failure and fear of success.

55

Individuals with substance abuse will often relate to fear of success, particularly those with very long histories of use. People with histories of trauma typically have a difficult time experiencing vulnerability. Fear of success can open a person up to a heightened sense of vulnerability, which can also interfere with committing to something outside their habitual way of living. Perceived interpersonal rejection and fear of letting others down (again) can be an internal barrier for many patients in the group. Validate these experiences and express that all committed action inevitably involves discomfort and unwanted internal experiences.

Setting Goals Ask group members if they are willing to pair up with the person next to them to complete a worksheet on goal-setting. Hand out Setting Goals Worksheet (See page XX).

Instruct patients to write their goals on the sheet without using any slogans, mottos, clichés, aphorisms, sayings, words of wisdom, jargon, catch-phrases, steps, or lingo. As patients work in pairs, ask them to help each other set concrete examples of what each person would like to change, and how things would be different if this was changed. For each goal, ask patients to think of one thing that can get in the way of sticking to his or her commitment. And then, identify specific things each person will do when these things happen.

Homework AssignmentHand out Committed Action Worksheet (See page XX) for homework. Answer any questions about completing it.

56

Setting Goals Worksheet

Instructions: Write down your goals on the sheet. Use specific examples of what you would like to change, and how things would be different if it were. For each goal, think of one thing that can get in the way of sticking to your commitment. Even more important, think of specific things you will do when these things happen.

Goal #1 (write this in plain English, without catch phrases, slogans etc.):

Barrier (what is one thing that will get in the way of this goal)?

Plan (how will I deal with the barrier effectively)?







57


Homework Assignment

Committed Action Worksheet

The purpose of this worksheet is to identify some of your immediate goals in the service of your longer-term values. For each goal, write down the likely obstacles to that goal (the things that will get in the way or make you hesitate to make a change). Then write down what you can do about that obstacle. Note whether it is something you can change or whether it is something you will have to live with.

Goal Obstacles

What can I do about the obstacles?(Can I change them? Do I have to put up with them?)



The Swamp Metaphor,

58

“This is like you are beginning a journey to a beautiful mountain you can clearly see in the distance. No sooner do you start the hike than you walk right into a swamp which extends out as far as you can see in all directions. You say to yourself, “Gee, I didn’t realize that I was going to have go through a swamp. Its all smelly and the mud is all mushy in my shoes. Its hard to lift my feet out of the muck and put them forward. I’m wet and tired. Why didn’t anybody tell me about this swamp.” When that happens you have a choice: abandon the journey or enter the swamp. Therapy is like that. Life is like that. We go into the swamp not because we want to get muddy but because it stands between us and where we are going”

Another way to legitimize the appearance of new obstacles is reframe it as a sign of positive growth. There is an old saying in strategic therapy that applies here: “Life is one damn thing after another. Our job is to make sure it’s not the same damn thing.” The necessity of growth and struggle together in life is a hard message to hear and it certainly gets only flimsy support from the language community.

59



Review of ACT ProtocolReview of Monday curriculum and overall concepts of model introduced in protocol for new patients. Ask patients for thoughts on Wednesday Quiet Reflection and relate discussion points to making commitments to valued living.

Long-term and Short-term Consequences of RecoveryFacilitate discussion among group members about actions chosen based on short-term and long-term discomfort. What does using substances help individuals gain in the short term? Long term? What does using substances cost in the short term? Long term? People generally choose not to act because we want to avoid short-term discomfort, yet we are able to ignore very severe long-term consequences in order to avoid immediate discomfort.

Early in recovery, it is often the case that patients can recall more of the negatives of using substances. When asked, there are many reasons a patient can cite for wanting to remain clean. The long term positives can also be easily listed, such as re-establishing relationships and maintaining financial stability. However, as more clean time is acquired, the negative consequences of using become less salient. Once these negatives of using disappear in recovery, one is in danger or relapse.

Scale MetaphorAsk group participants to connect with their reasons for making a change with their substance use. Ask for specific negative consequences of substance use. Allow time for a large list to develop; the group leader should write the responses on the dry erase board. Next, ask patients to list the reasons they have used in the past. At first, patients may resist connecting with positives of drug use, stating there are no good reasons to use. Help patients to identify with the idea that something was beneficial about using. The importance of recognizing what this was will help them recognize it in the future, because the thought will pass through their heads again. There is no shame or judgment in knowing that – it is simply a thought that they can choose not to act on.

Write all negative consequences on one side of the dry erase board and positives on the opposite side, representing a scale. List enough to balance both sides equally. Notice out loud to patients how both sides balance out early in recovery.

Then discuss the process of recovery, as one begins to build more positive things into his or her life, the negative consequences become less prominent. For example, with more clean time, it becomes easier to find stable employment. With regular paychecks, housing and transportation become less of an issue. There are typically less legal consequences when one is engaging in these types of law-abiding activities. As the group leader lists each one, he erases this concept from the negatives side of the scale. Notice with patients how empty the negative side can become after several months of

60

clean time. Emphasize the fact that the focus needs to shift on the long-term benefits of recovery in order to continue with sobriety, or maintaining weight on both sides of the scale. If patients continue to focus on the absence of negative consequences, they may be left with little to rely on to maintain motivation after some clean time.

Commitment BalanceHand out journal group assignment, Commitment Balance (See Page XX). Relate this to the scale just created on the dry erase board. Discuss with patients that this worksheet is their own personalized scale. Identify the importance of recognizing their own reasons for wanting to remain clean. Identify the difficult times and struggles that may increase their urges to use – that this exercise will become crucial in those moments. Facilitate discussion about how this assignment may best be utilized in those moments (e.g., carrying a copy in their wallet, sharing with family and friends, etc).

Journal Group AssignmentAssign decisional balance to be worked on before next journal group. Answer any questions about assignment or how to complete it.

61


Journal Group AssignmentCOMMITMENT BALANCE WORKSHEET

The purpose of this worksheet is to help you consider all the consequences of a decision, in order to help you decide whether to commit to changing your behavior. You can use the worksheet to help you examine your decision in any important area. Remember to pay close attention to how consistent each option is with your longer-term values (or the way you would like your life to be).

First, think of an area of VALUE in your life- what is something that is important to you?

Next, identify something about that area of your life that is not working for you. Then, choose another way of doing things that is more consistent with what you really value.

“Short-term” can be in the next hour, the next day, or the next week. “Long-term” can be a week from now, a month from now, or five years from now.

Remember, a commitment consists of the following: “It would work for me in my life to do this, and therefore I’m doing it.”

A commitment should not be made unless you’re 100% certain you intend to keep it. This doesn’t mean that you won’t sometimes slip and fail; it means that if this does happen, you will get back up, point yourself back in the direction you want to go, and keep going. It also means that you are committed to changing the obstacles that you can change, and you are willing to sit with the emotions, feelings, and thoughts that you can’t change.

Remember: Just do it

Intimate relationships, Recreation, Friendships, Family relationships, Work/employment Education/training, Giving back/Citizenship, Spirituality, Physical health/Well-being

62

Commitment Balance

Short-term Long-term

Positive Negative Positive Negative

If I continue to…

(What will happenIf I continue to dothings exactly as I am doing now)

If I change and start to...

(How will things be different if I change my behavior?)

63



“Just Do It.” Nike Slogan

Reflection Meditation: There is never a “good time” to make a change. Consequently, there is never a “bad time.” There’s only the present.

64

Patient Handouts

65

Acceptance and Commitment Training (ACT) Program Philosophy Statement

Pain is inevitable, suffering is optional.-- Sylvia Boorstein

We know that individuals with substance abuse problems or PTSD have a tendency to avoid painful memories and engage in behaviors to distance themselves from their pain. Although these strategies may have worked in the short term, we believe that efforts at avoidance are ineffective, and even harmful, in the long run. This program is about becoming willing to make more space in our lives so that we are able to hold all the painful thoughts, memories and experiences life has dealt us without dodging them through the use of substances, AND at the same time move in the direction we value.

We strive to find meaning in our lives by letting ourselves and others know what is really important to us – what we value most. This treatment isn’t about what is “good” or “bad,” or what is “right” or “wrong;” the most important question at stake here is, “How well has this been working for me?” One of our most important tasks is to honestly take stock of what actions, relationships and life activities will help us live a vital and valued life. For many of us, past or present behaviors such as substance use, avoidance due to PTSD, or other difficulties may be causing us to behave in a way that is out of line with our values.

In all of our activities in the ACT Program, whether they be group therapy, individual counseling, or informal interactions with each other, we will work on:

Willingness to experience the full range of feelings, memories, and thoughts that we have on a daily basis, without attempting to get rid of or avoid those that we find difficult or uncomfortable

Being able to make an honest evaluation of our actions and beliefs in order to determine how well they are working

Coping skills as alternatives for avoiding or using substances Developing and participating in a social network Commitment to moving forward in our lives, in a direction determined by our

individual values

This treatment is about living in a way that is rich, full, and vital, and that lines up with our values. In this program, we choose life.

66

Workability Quotes

"Life is "trying things to see if they work." Ray Bradbury

“I cannot say whether things will get better if we change; what I can say is they must change if they are to get better.”

Georg Christoph Lichtenberg

“If the only tool you have is a hammer, you tend to see every problem as a nail.” Abraham Maslow

The definition of insanity: Doing the same things you’ve always done and expecting different results.

67

How Do You Dig ?

As we discussed today, we all sometimes make the mistake of trying to dig our way out of a hole. Of course, this only gets us deeper and deeper in the hole. For Wednesday, I’d like you to work on identifying some of the things that you do that get you more and more STUCK!

In preparation for next week’s group, please identify 3 things that you do that are “digging” in your life – things that you do that are meant to solve your problems but just seem to work in the short term, don’t work at all, or maybe even make things worse. Anything that keeps you stuck would be considered “digging.”

Digging #1:

Digging #2:

Digging #3:

1. Like in the quicksand metaphor, could you be willing to stop struggling with your own thoughts, feelings, memories, bodily sensations, etc. – and instead just stay still, and be in contact with them? What reactions do you have to that idea?

2. What would you have to do in order to stop struggling? Imagine yourself actually doing this. What would it look like? What would you be doing instead?

How’s That Working For You?

70

Imagine that the course of your life depends on you steering a car down a road in the direction of what’s important to you. And so at the beginning of this process, you get into your car and take off down the highway. Unfortunately, whoever taught you how to drive told you that the way to steer the car is by holding onto and turning the rear-view mirror.

Now, you might be able to go a long way once you start down the road without anything much happening, depending on whether the road you’re on is straight, or whether there is much oncoming traffic, and so on. Eventually, however, the car is going to crash. So, what you do is dust yourself off, start the car again, grab the rear-view mirror, and start driving again. But you keep crashing!

The problem isn’t with the car, or with the driver; the problem is that you can’t steer a car with the rear-view mirror! What we’re working on here is about teaching you to put your hands on the steering wheel instead of the rear-view mirror. Our focus is less on where you have been, and more on where you are going and how to get there.

Reflection Question: Have I been steering my life using the steering wheel, or the rearview mirror? What would I need to do to plant my hands more firmly on the steering wheel?

71

Willingness Quotes

“If nothing changes, nothing changes.” Ernie Larson

“If you do what you always did, you’ll get what you always got.” Moms Mabley

Reflection Question: How can you stop doing what doesn’t work AND are you willing to try something different?

Requires ACCEPTANCE and WILLINGNESS and COURAGE

COURAGE (literally, to have heart): the attitude of facing and dealing with anything recognized as difficult or painful, instead of withdrawing from it

72

Control and Willingness

Identify a situation, person, or event that you have had difficulty accepting.

What thoughts do you have about this situation, person, or event?

What emotional reactions come up for you when you think about this situation, person, or event?

Who would you be IF you were able to accept this situation, person, or event exactly as it is? How would you be different? How would your life be different?

73

HEAVEN AND HELL

There’s another story that you may have read that has to do with what we call heaven and hell, life and death, good and bad. It’s a story about how those things don’t really exist except as a creation of our own minds. It goes like this: A big burly samurai comes to the wise man and says, “Tell me the nature of heaven and hell.” And the roshi looks him in the face and says: “Why should I tell a scruffy, disgusting, miserable slob like you?” The samurai starts to get purple in the face, his hair starts to stand up, but the roshi won’t stop. He keeps saying, “A miserable worm like you, do you think I should tell you anything?” Consumed by rage, the samurai draws his sword and he’s just about to cut off the head of the roshi. The roshi says, “That’s hell.” The samurai, who is in fact a sensitive person, instantly gets it, that he just created his own hell; he was deep in hell. It was black and hot, filled with hatred, self-protection, anger, and resentment, so much so that he was going to kill this man. Tears fill his eyes and he starts to cry and he puts his palms together and the roshi says, “That’s heaven.”

There isn’t any hell or heaven except for how we relate to our world. Hell is just resistance to life. When you want to say no to the situation you’re in, it’s fine to say no, but when you build up a big case to the point where you’re so convinced that you would draw your sword and cut off someone’s head, that kind of resistance to life is hell.

In the way we practice, we don’t say, “Hell is bad and heaven is good” or “Get rid of hell and just seek heaven,” but we encourage ourselves to develop an open heart and an open mind to heaven, to hell, to everything. Why? Because only then can be realize that no matter what comes along, we’re always standing at the center of the work in the middle of sacred space, and everything that comes into that circle and exists with us there has come to teach us what we need to know.

Life’s work is to wake up, to let the things that enter into the circle wake you up rather than put you to sleep. The only way to do this is to open, be curious, and develop some sense of sympathy for everything that comes along, to get to know its nature and let it teach you what it will. It’s going to stick around until you learn your lesson at any rate. You can leave your marriage, you can quit your job, you can only go where people are going to praise you, you can manipulate your world until you’re blue in the face to try to make it always smooth, but the same old demons will always come up until finally you have learned your lesson, the lesson they came to teach you. Then those same demons will appear as friendly, warmhearted companions on the path.

Pema ChodronThe Wisdom of No Escape and the Path of Loving-kindnesspp. 31-32

74

“Pain is inevitable; suffering is optional.”

This week we are discussing how we tend to make our problems worse and increase our suffering by refusing to accept reality as it is RIGHT NOW, and by our unwillingness to experience whatever thoughts, feelings, memories, and physical sensations accompany that reality. We call this “dirty discomfort.” In the story of the Samurai, the wise man taught him how he had created his own “hell” by his unwillingness to accept the situation for what it was.

3. How do you create “dirty discomfort” for yourself? How do you take a stressful situation and make it worse? In your journal entry, please write about something that happened today in which your unwillingness to accept the reality of the situation ended up making things WORSE for you!

4. Next, write about a situation that happened today in which your willingness to accept the situation as it was, and your willingness to “own” your feelings, thoughts, and reactions to the situation, brought you at least a little taste of peacefulness and calm…

75

Willingness Reflection

A. CONTROL AND AVOIDANCEOR

B. ACCEPTANCE AND WILLINGNESS

Identify the approach (A or B) that best fits each of the statements below:

____ When negative experiences occur, the goal is to get rid of them or get them under control so that they hurt less.”

____ The attempt to control or get rid of negative experiences creates problems; the goal is to let them be there, and they will change as a natural part of living.

____ The way to understand negative experiences is to understand why I am having them, and then use that knowledge to eliminate them.

____ The way to understand negative experiences is to notice that they are present without necessarily analyzing them or judging them.

76

Defusion Reflection

"Do we control what we think?"

Facilitate debate of this topic for 10 minutes

Reflection Question: What would it mean if we do control our thoughts and what would it mean if we don't actually control our thoughts?

RECOVERY POP-QUIZ

77

1. I think, therefore I am T F

2. If this program teaches me anything, T F it’s that avoidance is always unhealthy

3. The more I try to stop a thought, the stronger the thought becomes T F

4. In recovery, behaviors must change T F but my thoughts and feelings are OK the way they are.

78

Reacting to Uncomfortable Emotions

AVOIDANCEStuffing It------------------------------------------------------------------------Acting It Out

Responding to Uncomfortable Emotions:

EXPERIENCING IT"Sitting with it"

List two emotions that you wish you could get rid of.________________________________________________________________________________________________________________________________________________

How have you tried to avoid/get rid of each of the two emotions you listed?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How has trying to get rid of these emotions gotten in the way of living a valued life?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

79

Take Your Keys With You…

For your journal group assignment this week, identify several different emotions, thoughts, memories, or sensations you have been struggling with lately. These can be about trauma, substance abuse, or both.

Examples include:

“I don’t think I can ever stop using.” “I will never make up all my years of using to my family.” Tightness in chest, restlessness, or other sensations of anxiety and cravings Memories of your trauma

Write your own examples here:

1. _______________________________________________________

2.________________________________________________________

3. _______________________________________________________

Now, take 3 small pieces of paper. Write your examples on the papers. Then, tape the papers to 3 keys on your key ring. If you are willing, your homework is to carry your keys, and your thoughts, memories, feelings, and sensations, with you for the next week.

Journal about several things during the next week about your experience carrying your keys:

How much effort does it take to carry your keys with you?

What places can you go, or not go, depending on whether you have your keys with you?

Does picking up your keys and carrying them with you prevent your from going anywhere?

80

Cravings News Radio Metaphor

CRAVINGS NEWS RADIO (WSNR): “This is Cravings News Radio, WSNR, broadcasting inside your head, twenty hours a day, seven days a week. Wherever you are, the signal will reach you. When you wake in the early hours, we’ll be there to make you aware of your craving to smoke, even before you get out of bed. Let us take over and control your life. Cravings News Radio is compelling listening, and guess why? It’s the news station you’ve lived with for years, and now comes to you automatically, 24/7. Pay attention! Cravings News Radio knows what’s best for you and we want you to buy our products. We advertise the products you fear most and want to avoid. So don’t forget that, and remember, if you should forget us and ACT without seeking permission, then we’ll broadcast all the louder. Remember, having cravings can be really awful, so you should stay tuned to this station to know how to avoid them.”

JUST SO RADIO (WJSR): “Wake up! Cravings News Radio is just a station – you can tune in, or you can tune out! One thing is guaranteed though, whatever the time of day, you’ll hear the same old stuff on WSNR. If that’s been really helpful to you, then go ahead, tune in and stay tuned. That would make sense. If not, then tune in more often to Just So radio. We bring you the news of actual experience, in the moment, all live, all the time. Actuality is out business! We give it to you straight – as it is, not as your mind says it is. In contact with the world outside and inside the skin, you can experience what it is to be human, and it’s entirely free! We can guarantee that experiencing what’s inside the skin – exactly as it is – will never damage you, but it just might bring you joy. Just So Radio brings you information about how things are, not how you fear they might be. Just So Radio invites you to step forward and touch the world, just as it is, and to touch your life, just as it is. We get louder the more you listen to us. So stay tuned. Give us a fair trial, and if not convinced by your own experience (please don’t take our word for it) then WSNR 9 Cravings News Radio – is still there on the dial.”

81

Values ReflectionsA little over ten years ago, as I was beginning my journey to integrating sacred pampering and self-care into my life, I thought that having more joy and deep satisfaction in my life was a matter of “getting my priorities straight.” A priority is something we regard as more important than something else. But I discovered that having more joy in my life didn’t come about as a result of getting my priorities straight, but from having my actions and behaviors consistent with what I said I valued. What you value is what you consider significant and important.

An assessment of where, how, when, and with whom we invest our time and energy is an accurate and telling barometer for where our priorities lie. We think that we act in accordance with what we value. This is usually not the case. Most of us are usually doing the opposite—our actions and behaviors are supporting something very different from what we say is important to us. Unfortunately, this is the norm.

When your behavior is at odds with what you value, you experience anxiety, dissatisfaction, “spiritual constipation,” and internal conflict. These are by-products of the head-on collision of our behaviors and our values. What you value is a function of your beliefs. Someone’s values, and thus his or her beliefs, show through a person’s actions, behaviors, and choices. In other words, demonstration is the vehicle through which our values are revealed. When you say your values are one thing yet your actions and behaviors demonstrate another, you undermine your power, integrity, and spiritual energy.

Debrena Jackson Gandy, from All The Joy You Can Stand

You don’t get to choose how you’re going to die. Or when. You can only decide how you’re going to live. Now.

Joan Baez

He who is not courageous enough to take risks will accomplish nothing in life. Muhammed Ali

82

“When the process of living becomes the outcome of interest, we are no longer living in a world of deprivation.”

How am I practicing living fully today?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What are some goals that are consistent with my values that can help me move forward this week?

4. __________________________________________________________________5. __________________________________________________________________6. __________________________________________________________________

83

Values ReflectionFROM: You can't stop the waves but you can learn to surfJon Kabat-ZinnWherever you go there you are, pp 30-31.

People who come [here] quickly learn that stress is an inevitable part of life. While it is true that we can learn, by making intelligent choices, not to make things worse for ourselves in certain ways. There are so many things over which we have little or no control. Stress is part of life, part of being human, intrinsic to the human condition itself. But is does not mean that we have to be victims in the face of large forces in our lives. We can learn to work with them, understand them, find meaning in them, make critical choices, and use their energies to grow in strength, wisdom, and compassion….

One way to envision how [this] works is to think of your mind as the surface of a lake or of the ocean. There are always waves on the water. Sometimes they are big, sometimes they are small, and sometimes they are almost imperceptible. The water's waves are churned up by winds, which come and go and vary in direction and intensity, just as do the winds of stress and change in our lives, which stir up waves in our minds.

84

Please choose three areas (listed below). Then write about what you would like to be doing in that area. Finally, write some barriers to achieving these goals.

Valued Areas of Life

Intimate relationships FriendshipsFamily relationships Work/employmentEducation/training RecreationGiving back/Citizenship Spirituality

Physical health/Well-being

Example:1a. Education1b. Want to improve my education by pursuing my GED.1c. Need to focus on treatment and work right now.

1a. Area of Life: _____________________________



2a. Area of Life: _____________________________


85


3a. Area of Life: _____________________________



86

Values ReflectionImagine that you selected a spot to plant a garden. You worked the soil, planted the seeds, and waited for them to sprout. Meanwhile, you started noticing a spot just across the road, which also looked like a good spot—maybe even a better spot. So you pulled up your vegetables and went across the street and planted another garden there. Then you noticed another spot that looked even better. Values are like a spot where you plant a garden. You can grow some things very quickly, but other things require time and dedication. The question is, “Do you want to live on lettuce, or do you want to live on something more substantial—potatoes, beets, and the like?” You can’t find out how things work in gardens when you have to pull up stakes again and again. Of course, if you stay in the same spot, you’ll start to notice its imperfections. Maybe the ground isn’t quite as level as it looked when you started, or perhaps the water has to be carried for quite a distance. Some things you plant may seem to take forever to come up. It is at times like this that your mind will tell you, “you should have planted elsewhere,” “This will probably never work,” “It was stupid of you to think you could grow anything here,” and so on. The choice to garden here allows you to water and weed and hoe, even when these thoughts and feelings show up.

Reflection Question: What is your garden and what commitment can you make to it this week?

87

Setting Goals Worksheet

Instructions: Write down your goals on the sheet. Use specific examples of what you would like to change, and how things would be different if it were. For each goal, think of one thing that can get in the way of sticking to your commitment. Even more important, think of specific things you will do when these things happen.










88

Committed Action Worksheet

The purpose of this worksheet is to identify some of your immediate goals in the service of your longer-term values. For each goal, write down the likely obstacles to that goal (the things that will get in the way or make you hesitate to make a change). Then write down what you can do about that obstacle. Note whether it is something you can change or whether it is something you will have to live with.

Goal Obstacles

What can I do about the obstacles?(Can I change them? Do I have to put up with them?)

COMMITMENT BALANCE WORKSHEETThe purpose of this worksheet is to help you consider all the consequences of a decision, in order to help you decide whether to commit to changing your behavior. You can use the worksheet to

89

help you examine your decision in any important area. Remember to pay close attention to how consistent each option is with your longer-term values (or the way you would like your life to be).

First, think of an area of VALUE in your life- what is something that is important to you?

Next, identify something about that area of your life that is not working for you. Then, choose another way of doing things that is more consistent with what you really value.

“Short-term” can be in the next hour, the next day, or the next week. “Long-term” can be a week from now, a month from now, or five years from now.

Remember, a commitment consists of the following: “It would work for me in my life to do this, and therefore I’m doing it.”

A commitment should not be made unless you’re 100% certain you intend to keep it. This doesn’t mean that you won’t sometimes slip and fail; it means that if this does happen, you will get back up, point yourself back in the direction you want to go, and keep going. It also means that you are committed to changing the obstacles that you can change, and you are willing to sit with the emotions, feelings, and thoughts that you can’t change.

Remember: Just do it

Intimate relationships, Recreation, Friendships, Family relationships, Work/employment Education/training, Giving back/Citizenship, Spirituality, Physical health/Well-being

90

Short-term Long-term

Positive Negative Positive Negative

If I continue to…

(What will happenIf I continue to dothings exactly as I am doing now)

If I change and start to...

(How will things be different if I change my behavior?)

91

Committed Action Reflection

“Just Do It.” Nike Slogan

Reflection Meditation: There is never a “good time” to make a change. Consequently, there is never a “bad time.” There’s only the present.

92

acceptance and commitment therapy group therapy web viewacceptance and commitment therapy group...

Documents