An Acceptance-Based Behavioral Therapy for Individuals with Generalized Anxiety Disorder

Abstract

In response to clinical observations and research findings that individuals with Generalized Anxiety Disorder are reactive to their internal experiences, avoid and suppress painful emotions, thoughts, and sensations, and limit their involvement in meaningful activities, an Acceptance Based Behavioral Therapy (ABBT) was developed to specifically target these responses. ABBT incorporates acceptance and mindfulness strategies with more traditional behavior therapy techniques. Specifically, ABBT uses mindfulness and acceptance approaches as an alternate response to the rigid, avoidant responses characteristic of GAD. Likewise, therapy focuses on identifying and enacting behaviors that are congruent with what is personally meaningful to the client rather than engaging in actions that are motivated by avoidance of anxiety. This article provides a case conceptualization from an ABBT perspective for “William,” the composite client presented in Robichaud (this issue). The article goes on to demonstrate how an ABBT approach to treatment may unfold session-by-session for “William.”

Often individuals who experience generalized anxiety disorder (GAD) or chronic worry report that they are consumed by their worries in a way that leads them to miss out on their present experience. Likewise, simply having anxiety can lead to a strong desire to change the content, intensity, or frequency of internal experiences (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). At the same time, individuals with GAD often make behavioral choices based on decreasing anxiety rather than on engaging in meaningful activities, thus constricting their behaviors. In response to clinical observations and research findings that individuals with generalized anxiety struggle with their internal experiences (e.g., thoughts, emotions, physical sensations, urges, images), avoid and suppress painful experiences (i.e., experiential avoidance), and limit their involvement in meaningful activities (behavioral constriction), an acceptance based behavioral therapy (ABBT) was developed to specifically target these responses. ABBT is firmly rooted in behavioral traditions to treating GAD (e.g., Borkovec, Newman, Lytle, & Pincus, 2002) and draws heavily from a number of approaches that have incorporated acceptance and mindfulness based strategies, including Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999), Mindfulness-based Stress Reduction (MBSR; Kabat-Zinn, 1990), Mindfulness-based Cognitive Therapy (MBCT; Segal, Williams, & Teasdale, 2002) and Dialectical Behavior Therapy (DBT; Linehan, 1993).

Review of Rationale for this Model of Anxiety

In reviewing the model of anxiety presented here, several terms are used that may be unfamiliar to readers. Therefore, a glossary of terms is included in the appendix.

Individuals with GAD often have problematic relationships with their internal experiences characterized by judgmental reactions to these internal experiences along with an over-identification or fusion (Hayes et al., 1999) with these experiences. For example, individuals with symptoms of GAD report greater negative reactivity toward their emotions (Lee, Orsillo, Roemer, & Allen, 2010; Mennin, Heimberg, Turk, & Fresco, 2005), view their worrisome thoughts as more dangerous and uncontrollable (Wells & Carter, 1999), and report intolerance of thoughts and feelings related to uncertainty (Dugas, Gagnon, Ladouceur, & Freeston, 1998) compared to individuals with lower levels of GAD symptomatology. These critical, judgmental reactions to natural responses like fear or doubt amplify and prolong distress. Further, emotional states like sadness or fear are often experienced as constant and defining characteristics rather than as temporary states that ebb and flow over time, which can make them seem threatening and all encompassing.

At the same time, one function of anxiety is to narrow the focus of attention onto threat relevant information so that only anxiety-consistent information is attended to, contributing to a feeling of being defined by anxiety. Viewing internal experiences such as anxious feelings or worrisome thoughts as potentially dangerous, all-consuming, and permanent, can motivate individuals to try and feel or think something else, and if that fails, elicit a strong urge to escape or avoid one’s internal experiences. However, distress can be paradoxically increased by this experiential avoidance, or the internal strategies aimed at suppressing anxious thoughts, feelings, or sensations, decreasing their frequency, or changing their form (e.g., Hayes et al., 1996). In fact, there is some evidence that worry itself can serve an avoidant function in that worry can initially reduce the physical arousal associated with anxiety (Borkovec & Hu, 1990) and individuals diagnosed with generalized anxiety disorder are more likely to report that they worry to distract themselves from more emotional topics (Borkovec & Roemer, 1995). Thus, a self-perpetuating cycle of anxiety develops in which critical, avoidant reactions to internal experiences trigger attempts to suppress and avoid, which compound distress, cuing more negative reactions and stronger avoidance efforts.

Likewise, this unwillingness to experience what is perceived as dangerous, constant, and self-defining anxiety can lead to avoidance of situations that elicit anticipatory anxiety. Because this behavioral avoidance is immediately reinforced by a reduction in anxiety, it then becomes easier to avoid in the future, resulting in a pattern where avoidance becomes a habitual response to anxiety-provoking situations. Some support for this theory comes from the finding that individuals diagnosed with GAD report living less consistently with what matters to them than individuals not diagnosed with GAD (Michelson, Lee, Orsillo, & Roemer, in press). As an added obstacle to living an engaged life, the intense cognitive effort associated with monitoring and managing one’s internal experience can make it difficult to notice and appreciate the present moment.

Treatment approach

If anxiety is maintained through problematic and reactive relationships with internal experiences, experiential avoidance, and behavioral constriction, then a treatment that addresses these components should be efficacious. Specifically, treatment should modify one’s relationship with internal experience, decrease rigid, habitual avoidance, increase flexible responding to internal and external cues, and increase action in areas that are of importance to the individual so that the focus is more on engagement than on avoidance. Accordingly, Roemer and Orsillo (2007; see Roemer & Orsillo, 2009 for a more detailed description of the treatment approach) developed an acceptance-based behavioral therapy (ABBT) for GAD. This treatment, which is presented in more detail below, incorporates acceptance and mindfulness strategies with more traditional behavior therapy techniques. Specifically, ABBT encourages clients to develop a more accepting, compassionate, and open relationship to their internal experiences through therapist modeling, psychoeducation, and mindfulness exercises. Mindfulness refers to “an openhearted, moment-to-moment, non-judgmental awareness” (Kabat-Zinn, 2005, p. 24). This acceptance, or recognition that experiences will come and go and that judging or resisting them is not useful, is counter to the experiential avoidance maintaining anxiety. As such, mindfulness and acceptance are presented and practiced as an alternate response to internal experiences. Likewise, therapy focuses on identifying and enacting behaviors that are congruent with what is personally meaningful to the client, termed valued action (Wilson & Murrell, 2004). This focus on valued action includes a specific focus on recognizing the obstacles to these actions, which are often internal (e.g., anxiety) as well as external. The focus is on making choices to act in value-consistent ways rather than in ways that are motivated by avoidance of anxiety.

Research findings

To date, two studies have examined the efficacy of ABBT. In these studies, ABBT led to significant improvement in symptoms in both an open trial (Roemer & Orsillo, 2007) and in a wait list controlled trial (Roemer, Orsillo, & Salters-Pendneault, 2008). In the open trial, the clients, all who were diagnosed with GAD, reported significant changes in their GAD severity, worry, and anxiety symptoms from pre to post treatment and at a three month follow-up assessment. Likewise, in the wait list controlled trial, clients, again all diagnosed with GAD at pre-treatment, showed significant improvement on GAD severity, worry, and depression. At post-treatment 75% of clients receiving ABBT were considered treatment responders, compared to 8% of those on the wait list. In terms of research on the proposed mechanisms of change for ABBT, clients have reported significant changes from pre to post treatment on measures of experiential avoidance (Roemer et al., 2008), reported anxiety about emotional responses and intolerance of uncertainty (Treanor, Erisman, Salters-Pedneault, Orsillo, & Roemer, in press), time spent accepting internal experiences and engaging in valued activities (Hayes, Orsillo, & Roemer, 2010), and measures of how consistent actions are with what matters to the individual (Michelson et al., in press).

Potential benefits in contrast to standard CBT for GAD

Recently, a number of novel behavioral treatments for GAD have been developed, many of which are presented in this special series, including therapies targeting metacognitive awareness (Wells, this issue; Wells, 2007), intolerance of uncertainty (Robichaud & Baker, this issue; Robichaud & Dugas, 2006), emotion regulation (Mennin, this issue; Mennin, 2004), and interpersonal components (Newman, Castonguay, Borkovec, Fisher, & Nordberg, 2008). As is true with many of these treatment approaches to GAD, ABBT falls under the broad umbrella of behavioral approaches to treatment and is consistent with traditional behavior therapy in a number of ways. However, in order to address the specific processes proposed to underlie GAD, there are some modifications and differences in emphasis from some traditional CBT approaches (which is also the case with other novel treatments presented in this series). The most notable difference is the way that thoughts are addressed. In some traditional CBT approaches, there is a focus on identifying and modifying maladaptive thought content (e.g., Beck, 1976; Clark, 1986) because irrational content is thought to cause anxiety. In contrast, as the current model assumes that it is the avoidant function of worry that is problematic, rather than the specific content of the worry, ABBT focuses on changing the reactions or responses clients have to thoughts and other internal experiences. An assumption underlying ABBT is that it is not the initial thought, worry, or feeling that is problematic, but rather the rigid unwillingness to have the internal experience that leads to distress. Therefore, the focus of treatment is not on eliminating the worry.

ABBT shares some similarities with traditional exposure models, in that clients are encouraged to approach situations and engage in activities while experiencing difficult thoughts and feelings. However, two somewhat unique methods are used to supplement traditional behavioral methods in achieving this goal. First, mindfulness exercises are used to help clients observe and experience their internal experiences as less negative, threatening, and defining and with more openness. Second, values exercises are used in which the focus is on engagement in personally meaningful experiences as a way of living rather than approaching anxiety provoking situations with the goal of extinction as is characteristic of many traditional exposure based approaches.

There is some empirical support for the importance of these two therapeutic processes in ABBT. Specifically, we have found changes in acceptance and valued action predict outcome above and beyond change in worry (Hayes, Orsillo, & Roemer, 2010). More research is needed to determine whether these processes also play a role in other therapeutic approaches to GAD and whether other processes (e.g., emotion regulation, intolerance of uncertainty) are also targeted in ABBT (e.g., Treanor et al., in press).

Application of the Model to the Clinical Case Conceptualization

Specific assessment strategies

As with most other forms of behavioral therapy, it is important to start with both an assessment of symptoms and a functional analysis of the anxiety to form a case conceptualization that is specific to the client. In this assessment, it is helpful to gather information on ways that anxiety has gotten in the way of the client living the life he or she wants to be living, ways that anxiety is pulling the client out of the present moment, and ways that the client attempts to control his or her internal experience. For example, we ask clients to complete the Valued Living Questionnaire (Wilson, Sandoz, Flynn, Slater, & DuFrene, 2010) which asks the respondent to rate how important various domains of living (e.g., family, work, spirituality) are to them and then asks how consistently they are living with each domain, and the Quality of Life Inventory (Frisch, Cornwell, Villanueva, & Retzlaff, 1992) which asks about the client’s satisfaction across several domains (e.g., work, helping, friends). It is also helpful to gain a better understanding about the client’s current relationship with his or her internal experiences. For example, measures such as the Affective Control Scale (ACS; Williams, Chambless, & Ahrens, 1997) assess the client’s distress about anxiety, depression, anger, and positive affective states. The Acceptance and Action Questionnaire (AAQ; Hayes et al., 2004) is a widely used measure designed to assess experiential avoidance. This self-report measure assesses both the unwillingness to remain in contact with one’s internal experiences and the unwillingness to act intentionally while experiencing distressing internal experiences. Together these measures can help the therapist to better understand the client’s current relationship with his or her internal experiences as well as to provide a way to assess change on these important constructs over the course of therapy.

Translation of “William’s” case presentation to the theoretical model

Consistent with an acceptance based behavioral approach, William, the composite client presented in Robichaud (this issue), expresses having 1) a difficult relationship with his internal experiences, 2) a pattern of experiential avoidance, and 3) behavioral constriction. Similarly to many clients with a diagnosis of GAD, William describes a difficult relationship with his internal experiences in that he describes himself as frequently being “in his head,” stuck or entangled with his internal experiences. Additionally, his attention is quickly consumed by the appearance of anxiety-related thoughts he judges to be unacceptable and intolerable, thus he engages in a number of experientially avoidant strategies aimed at avoiding them and/or changing their content. Further, his behaviors are constricted by his anxiety and worry in that he refrains from engaging in a number of activities, such as going on spontaneous outings or gardening, as a way of managing the distress he feels at the thought of having to make a decision. Please see Figure 1 for a schematic of the ABBT model of GAD.

Figure 1.

An ABBT model of Generalized Anxiety Disorder.

Reprinted from the Journal of Anxiety Disorders, 23 (8), Behar, DiMarco, Hekler, Mohlman, & Staples, Current theoretical models of generalized anxiety disorder (GAD): Conceptual review and treatment implications, pp. 1011–1023, Copyright (2009), with permission from Elsevier.”

William may notice that his worries increase as he assumes a new position as bank manager. In this new position, he notices that he is pulled out of the present moment by worries about both the decisions that he has to make and also thoughts and emotions about not being able to get the work done. For example, when on a conference call with his colleagues, instead of focusing on the content, William may spend a lot of mental energy worrying about how he might make mistakes on the project they are planning or how it might require too much time away from his family, which impairs his concentration and leaves him feeling irritable and fatigued. When these worries arise they likely cue a cascade of critical and judgmental reactions. For instance he might think that worrying this way means he is weak and not qualified to hold his position at the bank. He may dread the occurrence of worries, believing that he cannot effectively engage in his work until they are resolved. Imagining the horrible consequences that will ensue if his worries materialize is likely to increase his physiological arousal.

As the uncomfortable sensations, thoughts, and emotions grow in intensity, and make it more difficult to concentrate, William is likely to judge them even more harshly and to engage in whatever actions he thinks may help him escape from the “unacceptable” thoughts, emotions, and physiological arousal. William may use forms of experiential avoidance such as distraction, suppression, and/or self-talk in an attempt to calm his anxiety and clear his mind. Unfortunately, William’s internal distress is likely to increase exponentially as his attempts at distraction or suppression backfire. This might cue additional critical and judgmental thoughts about his ability to manage his anxiety. Further, given that William has always prided himself on being highly productive, when he is unable to participate effectively during the conference call, he is likely to judge himself harshly, which then increases his anxiety, making it harder to focus and concentrate on the task at hand, leading to more critical thoughts, thus perpetuating the cycle.

One way that William attempts to change his internal experience when experiential avoidance is not effective is to engage in behavioral avoidance. For example, he may cancel a conference call or make an excuse to terminate the call early. While in the short term, this may alleviate some of the anxiety and panic, it also elicits self-critical thoughts and painful feelings about his work performance given that behaving this way is inconsistent with his work-related values.

As a result of his entanglement in the cycle of worry and avoidance, William has experienced a narrowing, or constriction, in his behaviors across many valued domains. For example, although Williams tries to spend quality time with his daughter, he is often unable to be in the present moment when he is with her. Instead he finds himself distracted by his worries about work. Additionally, William’s difficulty concentrating on work and his procrastination is making him less efficient at work, so he is spending more time at the office and less time engaged in valued activities such as spending time with his family and gardening. William’s self-care is also suffering. For example, rather than getting the restorative sleep he needs, William finds himself caught up in a web of worry each night as he tries to plan for all the possible problems that might emerge at work the next day. The subsequent lack of quality sleep likely leads him to be more reactive to both his internal and external experiences, adding to the problematic relationships with his internal experiences.

The model provided here can be used to account for many of William’s other presenting problems. For example, William’s entanglement in worry and unwillingness to tolerate painful internal experiences prevent him from pursuing activities that he used to enjoy such as spontaneous social outings and gardening. When William thinks about initiating an outing or working around the yard, he easily imagines all the options available to him (like where he could go for lunch, or which fertilizer is best), as well as all the possible consequences of making the wrong decision. William frantically searches for the perfect solution, hoping to avoid the distress and regret that could accompany a wrong decision. As a way to escape this painful cycle, he eventually defers to his wife, allowing her to make all decisions about the gardening and their social life. Although the avoidance enables William to avoid the emotional pain, it also prevents him from feeling engaged in the life that he wants to be living.

Description of the Treatment Protocol using the Case Example of “William”

Clinical Considerations

Presented below is a brief example of how ABBT may be applied to William’s case. Additionally, Table 1 provides an overview of each session’s goals and content. The content is divided into psychoeducational content that is introduced, experiential exercises to demonstrate the content, and between session activities that the client is asked to engage in. For a more detailed description of ABBT, including specific descriptions of the exercises, please see Roemer and Orsillo (2009). While not always explicitly stated below, the first seven sessions of William’s therapy would be focused on presenting the underlying concepts central to ABBT as well as building the foundational skills (i.e., mindfulness, awareness of one’s internal experience, clarification of personal values). The remaining sessions would then be focused on applying the skills and concepts and maintaining gains. Throughout therapy, between sessions William would be asked to engage in mindfulness practice, monitor his internal experiences in a progressively more nuanced way, and to first explore and later take actions consistent with his values. These between-session activities would be reviewed at the beginning of every session, after the therapist led William through a mindfulness exercise. Mindfulness exercises would become progressively more challenging, first addressing physical sensations like the breath, eating, sounds, then emotions, then thoughts, and finally self-compassion and the transience of experience.

Table 1.

Session Goals and Content for ABBT

Session	Goals	Psychoeducation	Experiential Exercises	Between Session Activities
Initial	• Develop rapport • Understand client’s experience of anxiety, strengths, treatment history, current support, and hopes for treatment			• Read model of anxiety • Self-monitoring of worry • Self-assessment of values
1	• Provide case conceptualization and treatment plan	• Function of anxiety and worry • Rationale for acceptance and mindfulness	• Imaginal experience of anxiety • Mindfulness of breath	• Self-monitoring of worry • Mindfulness of breath practice
2	• Introduce the client to mindfulness	• Defining mindfulness as a process • Skills of mindfulness	• Mindfulness of breath • Raisin exercise • Progressive muscle relaxation	• Self-monitoring of worry • PMR practice • Informal mindfulness practice • Writing assignment – how is anxiety interfering with valued living
3	• Begin to change client’s relationship with emotion	• Function of emotion • Clear and muddy emotions	• Mindfulness of sounds	• Self-monitoring of worry and emotions • Formal and informal mindfulness practice • Writing assignment – how would you like to be acting in each valued domain
4	• Highlight the costs of control and avoidance • Differentiate values from goals	• Costs of efforts to avoid/control internal experiences • Values versus goals	• Awareness of physical sensations • Mindfulness of emotion • Exploding machine metaphor • Tug of war metaphor • Skiing metaphor	• Self-monitoring of emotions and efforts to control • Formal and informal mindfulness practice • Writing assignment – articulate 1–2 values in each domain
5	• Introduce acceptance and willingness as an alternative to avoidance and control	• Defining willingness • Values as choices	• The Guest House • Observer exercise • Swamp metaphor • Annoying Joe metaphor	• Self-monitoring of first reactions (thoughts, emotions, sensations), second reactions (efforts to control, muddy, acceptance) and actions • Formal and informal mindfulness practice • Values assignment revision if necessary
6	• Introduce the concept of committing to valued living	• Commitment as a process	• Clouds exercise • Inviting a difficulty in • 3 minute breathing space	• Self-monitoring of first and second reactions and actions • Formal and informal mindfulness practice • Writing assignment: making a commitment • Mindful monitoring of valued actions taken and opportunities missed
7	• Highlight how mindfulness and defusion can facilitate acceptance and willingness	• Understanding thoughts as thoughts and exploring their limitations	• The Mountain Meditation • Passengers on the bus metaphor	• Self-monitoring of first and second reactions and actions • Formal and informal mindfulness practice • Mindful monitoring of valued actions taken and opportunities missed
8–10	• Encourage client to practice acceptance and mindfulness while engaging in valued living • Identify and address obstacles		• Leaves on a stream • Therapist- and client- chosen mindfulness exercises at the beginning of each session and in session as needed	• Self-monitoring of first and second reactions and actions • Formal and informal mindfulness practice • Mindful monitoring of valued actions taken and opportunities missed
11	• Encourage client to practice acceptance and mindfulness while engaging in valued living • Identify and address obstacles		• Therapist- and client- chosen mindfulness exercises at the beginning of each session and in session as needed	• Self-monitoring of first and second reactions and actions • Formal and informal mindfulness practice • Mindful monitoring of valued actions taken and opportunities missed • Writing assignment: Treatment reflection
12	• Encourage client to practice acceptance and mindfulness while engaging in valued living • Identify and address obstacles	• Review treatment and identify goals for rest of treatment	• Therapist- and client- chosen mindfulness exercises at the beginning of each session and in session as needed	• Self-monitoring of first and second reactions and actions • Formal and informal mindfulness practice • Mindful monitoring of valued actions taken and opportunities missed
13–16	• Encourage client to practice acceptance and mindfulness while engaging in valued living • Identify and address obstacles • Prepare to retain skills post-treatment	• Identify strategies to use for maintenance and relapse prevention, distinction between lapse and relapse	• Therapist- and client- chosen mindfulness exercises at the beginning of each session and in session as needed	• Self-monitoring of first and second reactions and actions • Formal and informal mindfulness practice • Mindful monitoring of valued actions taken and opportunities missed

In addition to the specific techniques and content of the sessions, in ABBT the therapist’s stance is also an important component of the therapy. To help normalize William’s experience and to help him to adopt a more compassionate stance, his therapist would model therapy concepts throughout therapy. For example, his therapist would validate his struggles and his desire to avoid painful situations, while also encouraging him to move towards the distress and modeling a willingness to approach rather than avoid. His therapist would use language that enhances compassion, acceptance, and defusion (i.e., the ability to separate oneself from one’s thoughts and feelings). At the same time, the therapist may use examples from her or his own life to demonstrate how the processes underlying William’s generalized anxiety (e.g., tendencies to be critical toward and fused with internal experiences and avoid painful stimuli) reflect more universal human experiences.

Outline of a Session-by-Session Treatment Protocol for William

Prior to the first session, it would be important for William’s therapist to have met with him for both an initial assessment to determine if this is an appropriate treatment approach and to engage William in the therapy process. Most notably, given that most clients with GAD also carry several other comorbid diagnoses, before beginning ABBT, the therapist would want to determine whether GAD was the primary concern. Although ABBT has been shown to target associated problems such as depression, clients with active suicidal intent, bipolar disorder, psychosis, or current substance dependence may benefit from therapy aimed specifically at those problems. The therapist would also want to establish that William experiences distress and interference associated with his worry, central elements of the GAD diagnosis that are explicitly targeted by ABBT. For example, before beginning the first session, his therapist may meet with William in order to hear about the ways that anxiety and worry are interfering in his life and to hear about whether there are family or cultural factors that are relevant to his view of his anxiety or to the treatment process. In addition, his therapist may ask William about his view of therapy, any previous experiences with therapy, and potential obstacles to treatment. Here, his therapist may also elicit William’s hopes for treatment and a commitment to the time and effort needed to engage in therapy.

Session 1

After orienting William to the structure of therapy, the collaborative nature of the therapeutic relationship, and the expectations of out of session work, the focus would be on developing a shared understanding of worry, anxiety and the processes that underlie GAD in order to set the stage for treatment. An imaginal exercise in which William would be asked to put himself back in a recent worry situation may be used to highlight and illustrate multiple aspects of the anxiety process. For example, William might describe sitting at his desk at work, feeling anxious and overwhelmed, worrying about getting fired and wanting to put off working on the project since it made him so anxious. If William got anxious in session recounting this experience, his therapist may use this to highlight how our ability to think, imagine, and remember means that we may experience anxiety even when no threat is directly present. Also, his therapist might point out that fear has an adaptive function in that it prompts us to avoid potential threat. However, living a meaningful, engaged life, which can involve taking on a challenge at work or opening ourselves up to another person, requires us to approach a threat even when our natural response of anxiety signals a desire to escape. For example, even though William’s fears about not doing a good enough job on his project and being disapproved of or rejected by his boss are natural responses to social threats, he may still want to approach his work so that he can act consistently with his value of being a responsible worker. Next, William’s therapist may discuss the positive and negative functions of worry to help him develop more compassion towards his anxiety. Clients with similar presentations to William often talk about ways that worry has negatively affected their lives (e.g., pulls them away from relationship with loved ones, makes them feel like spectators in life). Clients sometimes have more difficulty identifying the positive aspects of anxiety, although William was able to note the motivating quality of his anxiety. William’s therapist would also introduce the notion that worry can serve an avoidant function, distracting us from other forms of distress.

At this point, clients are usually curious about what treatment will look like. The therapist working with William would highlight the three goals of treatment mapping them directly onto the previously presented model of GAD: 1) to increase awareness and cultivate a different relationship with internal experiences, 2) to increase choice and flexibility, and 3) to increase mindful action. In other words, the focus is on becoming more aware of the worry and anxiety cycle, practicing disengaging from these processes enough to be able to respond more flexibly and without rigid, habitual avoidance, and increasing engagement in desired activities and pursuits. When checking in about the model, William may initially ask about whether he would be anxiety free at the end of therapy. His therapist may respond by highlighting that while it is likely that William will experience less intense, distressing anxiety, he will not be anxiety free as anxiety and worry are both natural human responses. However, this treatment is likely to help him feel more satisfaction in life, more of a sense of choice, and more awareness in the moment, like when he is with his daughter.

In this session the first mindfulness exercise, mindfulness of breath, would be introduced. Video 1 provides an example of a brief mindfulness of breath exercise. In this example, mindfulness of breath was practiced only briefly; however, if this were an actual session, the exercise would have lasted for five or ten minutes. While this exercise is similar to diaphragmatic breathing, the focus here is on building awareness rather than changing one’s breathing. However, clients often report that this exercise also helps them to feel more relaxed. Occasionally, as the video illustrates, clients will find mindfulness of breath challenging. If they do, this can be an opportunity to demonstrate how difficult it is to stay in the present moment and the often critical and reactive nature of the mind.

Session 2

This session begins with a mindfulness exercise focused on following his breath and then reviewing his between session activities. Video 2 provides an example of dealing with issues of non-compliance with the between session assignments. Here, there is also a focus on the value of self-monitoring as a mindfulness exercise. Following this review, the session would likely focus on increasing William’s understanding of what is meant by the term mindfulness, specifically that mindfulness is a type of present-moment, non-judgmental and compassionate awareness that has its origins in Eastern spiritual and religious traditions and has more recently been integrated into many forms of therapy outside of the spiritual and religious contexts.

To help William better understand what is meant by mindfulness, his therapist may walk him through an exercise focused on mindfully eating a raisin. While many clients are originally skeptical of this exercise, afterwards, they often comment on how different this experience is compared to how one typically eats raisins. In particular, clients often notice how much more complex both the shape and the taste of the raisin was when they actually paid attention to it rather than assuming that they knew what the raisin would be like based on past experiences. Together, William and his therapist may talk about what it would be like to bring this “beginner’s mind” and mindfulness in general to other activities in his life, such as spending time with his daughter or working on projects for work. Video 3 provides an example of debriefing the raisin exercise highlighting the ways in which this exercise can be used to demonstrate beginner’s mind.

The rest of the session would likely focus on a progressive muscle relaxation exercise that is used as an activity to both increase mindfulness and reduce tension and on introducing the concept of “values” or the things that matter to William. Between sessions, William would be asked to practice both “formal” breathing and progressive muscle relaxation exercises as well as “informal,” in-the-moment mindfulness exercises such as mindfully spending time with his daughter. Formal practices involve setting aside time to intentionally build the skill of mindfulness, while informal practices involve applying mindfulness to daily living. As a way to begin thinking about his values, William would also be asked to write about the ways that anxiety and worry have gotten in the way of living the life that he wants to be living in three different areas: relationships, work, and personal development (including self-care, community involvement, etc).

Session 3

In this session, his therapist would begin the process of helping William to cultivate a different relationship with his emotions. As a first step towards changing the relationship William has with his emotions, his therapist may discuss with him the function of emotions. Together they would consider how emotions communicate important information to ourselves and others, help organize and prepare us for action, and deepen our experience of life.

Using an example from his monitoring form William may be able to see how the anger he felt when his boss asked him to take on another task at work was in response to an unfair distribution of work across the managers and that if his anger were expressed appropriately with associated verbal and non-verbal cues, his boss would more clearly receive the intended message. However, William also may notice that he felt too worried and anxious to let his boss know he was angry or to disclose that he was overwhelmed with his workload and that the anger he felt seems to be more than the situation called for. This may lead to a discussion of the difference between “clear” and “muddy” emotions.

Clear emotions are direct, informative responses to a situation. For example, feeling angry may be a clear emotion in this situation if William is treated unfairly. On the other hand, “muddy” emotions are influenced by a number of additional factors including past events, future concerns, and even failures in self-care. For example, William’s reaction in this situation may have been stronger than it would otherwise have been because he was exhausted from not having enough sleep the night before. Likewise, being asked to do one more task may set off a cycle of worries about losing his job, his home, and family and so his anger response may be amplified.

Clear emotions are also made muddy by our reactions to them. For example, when trying to leave work on time to get to his daughter’s soccer game, if William is asked to do one more task, he may experience feelings of panic and think “I can’t possibly do this task and leave on time,” which may lead William to feel incompetent and think “what’s wrong with me, I can’t handle even adding only one little thing. I’m sure my co-workers wouldn’t have a problem with this. Why aren’t I more efficient? If I can’t get a handle on these thoughts and feelings I will never be successful.”

William may then engage in efforts to change his thoughts and feelings, which are likely to elicit a cascade of complicated responses leading to more intense distress. This cycle of control being the problem is a central concept in therapy and a main focus of the next session and so it is helpful to highlight it here. In an effort to model more compassion, his therapist may say to him “It sounds like you have been trying really hard to balance work and family responsibilities, since both are so important to you, and that doing so brings up a lot of painful emotions.” She or he might work to help William begin to understand how bringing mindful attention towards emotional experiences can help identify their source, allowing them to seem less dangerous and providing more options for responding. Awareness of emotions is particularly important as clients move into the part of therapy focused on values work as the relationship between emotions and valued action is complex. Emotional pain, such as sadness, can be a sign that we are not living in accordance with our values. However, emotional pain, such as fear, can also be an obstacle to living in accordance with our values.

This is the first session in which William and his therapist would begin to explore his values and some of the ways that emotional pain is getting in the way of living according to his values. In going over the writing assignment that he completed, William might mention how his anxiety and worry prevent him from having the kind of relationships he values with his wife and daughter. In order to get him thinking about his values, his therapist would follow this observation up by asking William to describe how he would like these relationships to be. William might respond that he wanted to be more present, connected and emotionally available to them both. In terms of work, he might talk about how his anxiety leads him to procrastinate. When asked to elaborate on what made it difficult to focus on the task at hand, William might talk about how the anger that he feels about being someone who is not living up to others’ standards is so strong and aversive that he will do anything to not feel that pain in the moment. In the third domain, personal development, he might talk both about how his anxiety keeps him from speaking up at school board meetings even when he feels strongly about an issue and also that his anxiety about work leads him to feel guilty whenever he is not working, which has led him to give up on many of his personal hobbies. The goal of this exercise is to help William begin to articulate his personal values and recognize the ways in which anxiety, worry, and avoidance have prevented him from fully engaging in his life. William would be asked to write more over the week about how he would like to be in each of his valued domains (if worry and anxiety were not getting in the way).

Session 4

The focus of this session would be on exploring the possibility that experiential avoidance, or attempts to control one’s internal experience may be part of the problem. For many clients, this is a challenging session. First off, the idea that control efforts contribute to distress is antithetical to most clients’ conceptualization of their anxiety problem, making it difficult for them to consider using therapy to reduce efforts at internal control rather than to try and strengthen them. Also, this is the first session where mindfulness of emotions is practiced. Up until this point, clients have practiced mindfulness in emotionally neutral contexts and often find it calming or relaxing. In this session, a mindfulness of emotion exercise is used to highlight how being mindful in emotional situations can help us to identify the sources of pain and to increase awareness of our emotional responses. This is an important skill that is used throughout therapy.

Building on last session’s discussion of clear and muddy emotions, William and his therapist may talk about how although emotions are adaptive, many of us learned to respond to them as dangerous, negative, or problematic. For example, William may talk about how he has received messages from society and even his colleagues in the banking industry that he should be in control of himself and be “professional” at all times. In particular, he may comment that none of the other men that he works with ever appear to be anxious or overwhelmed. He may describe how as a child he used to tell himself that he wanted to be more in control of himself than his parents seemed to be. Hypothetically, he could believe that his parents’ difficulty controlling their emotions was the cause of their chaotic behavior.

His therapist may also point out how emotional pain does not necessarily mean that some change is needed. Often in order to open ourselves up to living meaningful lives, we experience emotional pain. For example, William could hypothetically spend some time talking about the loss of one of the few friendships that he highly valued as an adult. Over the last 10 years he may have became very close with an older, more experienced colleague named Richard whom he considered both a mentor and a friend. Although William may have experienced significant sadness when Richard died suddenly and unexpectedly following a stroke, he may acknowledge that having such a wonderful friendship was worth the risk of experiencing such a sense of loss.

At this point, William’s therapist would want to highlight how our natural instinct to avoid emotional pain coupled with the fact that emotional pain is often a necessary part of living a meaningful life leaves us in a paradox. To have a meaningful life means encountering emotional pain. There are a few ways that William could navigate this paradox. He could limit his life so that he never takes any risks, which would allow him to avoid some emotional pain, but would keep him from living the life he wants to be living. He could take action in the domains of life that are important to him while trying to control his worry and anxious responses.

Most likely William has been trying to do this for some time with mixed success. Clearly he is presenting for treatment because when he really needs to push worries out of his mind or calm his anxiety, these control strategies do not work. But, William may also have some difficulty seeing his efforts to control his anxiety as a problem, since he would likely attribute his success in school, work, and taking care of his brothers growing up as being directly related to his ability to control his actions. His therapist may choose to use this as an opportunity to talk about, and demonstrate using experiential exercises and metaphors, the limits to control.

William would be asked to consider that, although we can often control our behaviors, attempting to control our emotions, thoughts, and reactions perpetuate the cycle of anxiety discussed above. For some clients, highlighting the limits of our ability to control other’s behavior and the future is also relevant. His therapist may then help William see that there is a third option; that it is possible to engage in life in meaningful ways and be willing to experience whatever emotions, thoughts, and reactions arise. This would mean that when he is asked to take on a new project at work that he would still experience the clear emotion of fear that he will not be able to adequately finish the project in the time given; however, being willing to experience this fear and the uncertainty of how the project will turn out would allow him to have less of a muddy reaction to this fear, lessening the critical judgment and over-identification with internal experiences, and experiential avoidance and thus shortening the cycle described above. Video 4 provides an example of helping a client to identify the clear emotions associated with an event with work highlighting the connection between emotions and values.

The second half of this session would be focused on helping William verbalize and refine his values. This is typically done over a couple of sessions. Through these discussions about his values, William may decide that it is important to him to be an emotionally present father and husband. In terms of work, he may initially state that he values being a diligent and conscientious worker and to be someone that others can count on. In terms of the third values domain, William may say that he values a balanced life style where he allows himself to develop personal hobbies such as gardening, rather than feeling like he should be spending all of his time at work or with his family. Video 5 provides a brief example of clarifying values with a focus on differentiating goals from values.

Session 5

Building on session 4’s focus on navigating the paradox by increasing willingness, the focus here is on specific strategies on increasing willingness. Here a combination of metaphors and mindfulness exercises, such as Rumi’s (from Barks & Moyne, 1995) poem, “the Guest House,” are used to increase acceptance of emotional experiences. William’s therapist may also use the “Swamp Metaphor” (adapted from Hayes et al., 1999) to describe willingness.

William may be asked to imagine that he was on a journey to a beautiful mountain, but along the way he came across a disgusting, murky swamp that he does not want to walk through. However, if heading toward the mountain represents a valued direction to William, he would need to cross the swamp. Willingness is crossing the swamp, even if that means that there is a possibility of becoming wet or muddy. For example, willingness may be expressed in the thought “well, here it is, I better just roll up my pants and go for it.” On the other hand, if the swamp were to the side of the path, there would be no need to go through it – willingness is not experiencing pain just for the nobility of it, it is experiencing whatever arises while pursuing a direction that matters to the individual. William’s therapist would clarify that willingness also does not mean wanting; he does not have to roll around in the mud or particularly like how it feels. William is welcome to put on some hip waders and heavy plastic rain pants to try and make the trek less muddy. Yet, willingness means that even with this gear, if William trips and falls face first in the mud, he will still be willing to keep moving through the swamp.

Overall, the idea is that even though some strategies may decrease our struggle with internal experiences, we cannot live a valued life without being willing to experience the full range of clear emotions. William’s therapist may also talk about how mindfulness, particularly mindfulness exercises directed towards promoting decentering, or the ability to observe thoughts and feelings as objective events rather than personally over-identifying with them (Teasdale, Moore, Hayhurst, Pope, Williams, & Segal, 2002), can help increase willingness. These decentering mindfulness exercises will be introduced over the next several sessions.

Sessions 6 and 7

At this point, William has likely come up with a list of values, has developed a mindfulness practice that enables him to begin to sort our clear versus muddy emotions, and is considering trying acceptance and willingness as an approach. The next step in the treatment is for him to get ready to start enacting willingness and mindful awareness as he starts taking valued actions.

In these two sessions, his therapist will help him prepare to start taking actions by first discussing the process of committing to a values-consistent life. For example, William may be encouraged to think about and commit to intentions that are consistent with his values and carrying out these commitments even when difficult thoughts or feelings arise. Since commitment can be extremely difficult when entangled with one’s emotions, developing a more decentered perspective can disentangle the experience some making it easier to commit.

In order to help cultivate decentering, a variety of mindfulness exercises can be used. For example, William may be asked to do a mindfulness exercise focused on getting some distance from his internal experiences by placing thoughts or feelings on a cloud in the sky or on a leaf in a stream and watching them pass by. William may also be introduced to the three minute breathing space (Segal et al., 2002). This brief practice could be used to help William first notice the thoughts, feelings, and sensations that he is experiencing, then ground himself in the present by focusing on his breath, and finally expand his awareness back out. The breathing space can be used in moments when William notices that he is “in his head” rather than in the present moment with his family. Like many clients with GAD, William is actually living a very busy life and appears to be active in his valued domains. However, at least at the beginning of treatment, this activity was motivated by anxiety and guilt rather than values and William often found himself distracted and disengaged, like he was “going through the motions”.

Between sessions 6 and 7, William would monitor his behavior in a way that would allow him to become more aware of how he could become more deeply engaged in his life. Specifically, William would be asked to use his newly emerging mindful observation skills to notice when opportunities arise during the week where he could take action in a valued domain. If William does engage in the action, he would be asked to rate how mindful and present he was during the activity. If he passes up the opportunity, he would also rate how mindful he was and note the obstacles that prevented him from pursuing the valued action.

At the end of session 7, William may notice that he is ready to start committing to some valued actions. From the beginning, William has commented that one of the major effects of his worry is that he is not emotionally engaged with his daughter in the way that he would like. Because this action is likely to be immediately reinforcing and therefore likely to encourage him to engage in other valued actions, his therapist may encourage him to choose being emotionally engaged with his daughter as his first assigned valued action. Specifically, he may be asked to practice soccer with his daughter and when he notices that he is overwhelmed by thoughts about work, to be mindful of that and to bring his awareness back to his daughter.

Sessions 8–13

The focus of these sessions is on applying mindfulness and engagement in valued activities in William’s daily life. Throughout these sessions, in addition to having William continue a formal mindfulness practice, his therapist would help him to apply a number of concepts presented in therapy. For example, sessions may help him to open up to distress, notice and address control efforts by increasing willingness, bring compassion to internal experiences, clarify clear and muddy emotions, develop new valued actions, address barriers to valued actions, and bring mindfulness to current valued actions. While the session content will be dictated by the events in William’s daily life, generally sessions will include both concrete, reinforcing actions and more difficult actions. Likewise, some actions may be long term, like using mindfulness to be more present and engaged when spending time with his family, and others may be a single action like asking a coworker to change her behavior. Video 6 demonstrates one way that mindfulness and valued action may be utilized in response to stressful situations. This clip focuses on a discussion of the ways in which mindfulness may be useful even when it does not produce a relaxation response.

For example, in Session 9 William may come to session noticing that he has been worrying a lot about his daughter, particularly about how she is doing in school, how she is getting along with others, and whether or not she is eating properly. In addition to being distressed about the worries and the accompanying anxiety, William may notice that after he struggles with his experience for awhile and gets increasingly anxious, he tries to talk to his daughter to get reassurance that everything is ok by asking her about school and giving her advice about how to succeed and be healthy. Several times over the past week this discussion has ended poorly. In telling his therapist about his worries, William may begin worrying aloud and then may express that he knows that he should be able to just stop these worries by bringing himself back to the present, but that there must be something wrong with him because he cannot do this.

In this case, his therapist may first model a more compassionate stance by saying “when you love someone and care about them, it is natural to have thoughts and worries about their well-being; part of being human is struggling with how hard it is to accept that we cannot prevent the people we love from experiencing the full range of clear emotions, like fear or sadness.” William may then be asked to practice a mindfulness exercise focused on opening up to the distress (e.g., “Inviting a Difficulty In and Working it Through the Body”, Williams, Teasdale, Segal, & Kabat-Zinn, 2007). This exercise can be used both to help William slow down and step back from his current worries and to increase his self-compassion and willingness. After the exercise, his therapist may help him to identify the clear (fear that his daughter will be hurt, love for his daughter) and muddy (feeling rejected by his peers in his childhood, feeling judged by his peers at work, having the thought that he can and must prevent his daughter from experiencing any pain) aspects of his experience and may help him to recognize how in this situation, his efforts to control his thoughts and emotions made them stronger and prevented him from acting consistent with his parenting values.

With mindful clarity, William might be able to recognize that although grilling his daughter about her day and seeking reassurance are both driven by his desire to connect to and care for her, his behavior is actually having the opposite effect as it is upsetting her and straining their relationship. Towards the end of the session, his therapist may help William to develop a plan of noticing when he is worrying about his daughter, opening up to this experience compassionately, gently redirecting his attention back to what he is doing, and allowing his values rather than his emotions to guide his behavior.

Over Sessions 10 to 12, William and his therapist may focus on his work experience. Initially, William might make statements such as “If I weren’t such a procrastinator, I would not be behind on my work.” He may also disclose a fear that if he is compassionate or accepting in this domain he will be even more “lazy” and fall further behind. William’s therapist would likely respond by defining procrastination as failure to engage in valued actions because of internal obstacles. Although William believes that labeling himself as lazy or a loser is motivating, his therapist may ask him to mindfully observe the effect that this reaction has on his behavior. The therapist may use self-monitoring to demonstrate how the anxiety William feels about his work becomes more intense, and his urge to avoid stronger, the more critical and judgmental he becomes. William’s therapist may also ask him to do a mindfulness of emotion exercise to help him identify and move towards the guilt, sadness, and anger that he may feel about his work performance to counter his more typical avoidance reaction. In response, William may be able to take a more decentered perspective as he recognizes how the work pressure is muddied by his experiences in childhood, particularly his role as the one who got everything done in the family and his concerns that he will turn into his parents if he does not always work to capacity.

The next session may then involve refining some of his values, particularly his value that he wants to be a diligent, conscientious worker. For example, he may notice that as he has worked towards being diligent and conscientious, he has also become less accepting of anything that is not done perfectly. Instead, William may feel that he wants to be the type of worker who is diligent and conscientious, but who is not obsessed about getting every aspect of the job done perfectly. During this discussion, William and his therapist may also talk about balancing various values. For example, it is possible that William could strive to do everything perfectly, but doing this takes significant time away from his family. Therefore, William may try to think about how he wants to balance his value of being an emotionally present father and husband with his work ethic values. He may make the choice during this session to start delegating more work and to turn in work that represents diligence and conscientiousness, but not necessarily perfection. In order to do this, he is likely to encounter a number of obstacles, both internal such as his worries about the repercussions of turning in less-than-perfect work and external such as his coworkers not doing what he asks them to.

Session 12 may focus more concretely on addressing these internal and external obstacles. In terms of the internal obstacles, William may be encouraged to notice when he is having thoughts and emotions about not doing the work perfectly and to bring some compassion to these moments perhaps by reminding himself that part of being human is acknowledging and accepting our imperfection. He may also be encouraged to practice sitting with the distress of turning in a project that is less than perfect by doing a mindfulness exercise directed at inviting in the distress. In terms of the external obstacles, William and his therapist may problem solve when and how to delegate work using a role-played conversation. It may also be that William develops a plan of action in which he will notice the internal reactions that come up when he thinks about delegating, do a three minute breathing space to notice the various reactions and bring him to the present, remind himself of his values, and then bring mindfulness to the conversation that he then has with his co-workers.

Sessions 14–16

In addition to applying the various therapy skills, these last sessions also focus on relapse prevention and maintaining gains. Part of maintaining gains involves moving towards valued living as a process. Up until this point, William and his therapist may have been addressing specific situations in therapy. At this point, the focus will be more on developing a more generalized plan or plans based on what has been helpful for William. For example, William may notice that a lot of conflict arises when he seeks reassurance from his family and coworkers as a way to assuage his own anxiety. Ironically, he engages in these conversations because he cares about the relationships (e.g., he does not want his daughter to get hurt, he wants his co-workers to think he is diligent), but his constant reassurance seeking paradoxically causes interpersonal distress. Therefore William may develop a plan that whenever he notices an urge to seek reassurance from others that he will first notice the distress, then do a mindfulness exercise that helps to bring needed clarity, distance, or compassion to his experience, then consider the kind of parent, spouse, or co-worker he wants to be in each of these relationships, then take any valued actions that are indicated in the situation.

Reflections on Treatment and Recommendations

In many ways, William represents a typical case of an individual being treated with ABBT. However, because of the wide variety of ways that clients are affected by worry, ABBT for GAD can look very different for each client. While all concepts are typically presented to each client, they are applied flexibly depending on the needs of the clients and the amount of time spent on each component varies considerably. For example, some clients who present to therapy have become so avoidant and caught up in their worries that they are not aware of what they value and do not engage in much values-consistent activity, while other clients lead very full, active values-consistent lives, but really struggle with being fully present or self-compassionate. While therapy for the first case may focus more on helping the client to identify and become engaged in values, therapy for the second may focus more on mindfulness and compassion. Likewise, because values are inherently individual specific, the actual content of the work will vary widely.

Clients presenting for treatment often have complicated and busy lives, possibly because of being a single parent of young children or because of the amount that they have to work in order to provide for themselves or their families. Because of this, treatment often needs to be applied in ways that are feasible for the clients. For example, for a single mother with young children, it may be near impossible to set aside consistent time everyday for formal mindfulness practice. In this case, in addition to helping her problem solve ways to fit the practice into her life, the therapist may also emphasize more informal mindfulness exercises with her.

While ABBT is designed to be applied flexibly depending on clients’ needs, it does follow a general progression. Because most of the ideas presented in ABBT are new to clients, the first several sessions are focused on introducing the model to the clients and providing psychoeducation and experiential opportunities to develop a deeper understanding of the concepts. At the same time, clients are beginning to develop the basic skills of mindfulness practice applied to relatively neutral contexts, such as breathing, eating, and listening to sounds and are beginning to more carefully consider the ways in which worry and avoidance are interfering in their lives. As clients gain practice with mindfulness, they are challenged to bring the skills to more emotionally charged contexts, such as being mindful of painful thoughts, emotions and physical sensations. Toward the end of the first half of therapy, the client should have a regular mindfulness practice and should be starting to use mindfulness skills to approach rather than avoid situations. They should also be able to better identify complex emotional responses and bring a more decentered and accepting stance towards their internal experiences. Also by the halfway point in therapy, clients should have identified their core values across the three domains and be willing to commit to engaging in actions consistent with these values even if doing so brings up difficult thought, feelings, or sensations. Then, the latter half of therapy focuses predominately on applying the core ABBT concepts to life and addressing obstacles that arise. For example, clients commit to taking valued actions each week, use their mindfulness skills in response to difficult reactions that arise and describe their successes and failures each week in session so that new habits can be reinforced and problematic behaviors identified and addressed. ABBT then ends with a focus on relapse prevention and maintaining gains.

Future Directions

While ABBT has shown significant promise in the treatment of GAD, it is a relatively new treatment approach. Thus, there are many questions about the treatment that have not yet been addressed. For example, more work is needed to compare ABBT to other therapy approaches and one such trial is currently underway. As additional research on the efficacy of ABBT is begin conducted, it is also important to understand which principles of this therapy are most central. At this stage, we believe that the key elements of ABBT include having a less rigid, more decentered response to one’s internal experiences, allowing internal responses to happen without out rigidly trying to change or control them, and engaging in meaningful activities rather than rigidly avoiding anxiety-provoking situations, however, this still needs to be empirically evaluated. In addition to better understanding the key mechanisms behind ABBT, we also need to learn more about whether we can begin to predict who is likely to benefit most from this approach.

Also, more work is needed to determine the ways that ABBT does and does not need to be adapted in order to be most useful to clients from backgrounds other than that of the White, heterosexual, middle-class client that is most often represented in therapy research. For example, it is likely that some of the metaphors that are typically employed would need to be modified to be more culturally consistent. For instance, it has been suggested that Latino(a) clients may benefit from metaphors and exercises that are more relationally based (La Roche, D’Angelo, Gualdron, & Leavell, 2006). Attention also needs to be paid to sensitively applying the model to validate culturally-based values, as well as the pain and distress resulting from sources of systemic oppression (see Lee, Fuchs, Roemer, & Orsillo (2009) for further discussion of these issues).

More research is needed to determine multiple potential modalities for delivering this treatment. Although we have been using individual therapy, a group environment may be beneficial for psychoeducation, skills training, and valued action groups. Contexts that can help support and maintain client change should also be identified; we encourage clients to pursue meditation, yoga, or other groups to support their ongoing practice when they leave treatment, but it would be helpful to have a broader range of options to present. We are also interested in examining how best to present these principles in a self-directed format in order to reach a wider range of individuals.

Another important area for future study concerns the optimal form and quantity of mindfulness practice. We have chosen to be flexible in encouraging practice, preferring clients to choose a practice of short duration that they are able to regularly engage in, rather than attempt longer practices but stop early or fail to practice all together. As with all forms of skills training, spending more time practicing is likely to be more beneficial. However, we have treated several clients who were never able to establish a regular formal practice, yet practiced informally throughout the course of their daily lives and clearly demonstrated improvements in the skills this practice targets. For this reason, while we work with clients to help them establish some type of regular formal practice, we will also give this up if it is not happening and the client seems to be developing mindfulness skills nonetheless. More research is needed to provide clinicians with guidelines for making these types of decisions.

Supplementary Material

Video 1

Video 1 – Mindfulness of Breath

Video 2

Video 2 – Compliance Issues with Self-Monitoring

Video 3

Video 3 – Debriefing the Raisin Exercise

Video 4

Video 4 – Identifying Clear Emotions

Video 5

Video 5 – Values versus Goals

Video 6

Video 6 – When Mindfulness Practice Isn’t Relaxing

APPENDIX

Glossary of Terms

Acceptance

Allowing what is to be rather than wishing or trying to make it other than it is

Behavioral Constriction

A limitation in the number or quality of activities engaged in

Beginner’s Mind

A fresh and fully aware perspective to whatever is happening as opposed to making assumptions about the situation

Clear vs. Muddy Emotions

Clear emotions are direct, informative responses to a situation whereas muddy emotions are more intense than the present context calls for or are unrelated to the present context

Decentering or Defusion

the ability to observe thoughts and feelings as objective events rather than personally over-identifying with them

Experiential Avoidance

The internal strategies aimed at suppressing anxious thoughts, feelings, or sensations, decreasing their frequency, or changing their form.

Formal vs. Informal practice

Formal practices involve setting aside time to intentionally build a skill, while informal practices involve applying mindfulness to daily living

Internal Experiences

This term is used to represent unobservable processes such as thoughts, emotions, physical sensations, urges, and/or images.

Mindfulness

A type of present-moment, non-judgmental and compassionate awareness

Valued Action

The identification of and engagement in behaviors that are congruent with what is personally meaningful

Willingness

The acceptance of internal experiences as a condition of engaging in valued actions