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درمان پذیرش و تعهد برای درمان اضطراب فراگیر

Acceptance and Commitment Therapy for the Treatment of Generalized Anxiety

 

*The reference tomanual’ refers to Orsillo and Roemer’s Treatment Manual for Generalized Anxiety Disorder.  The reference to ‘text’ refers to Hayes, Stroshal, and Wilson (1999).

 

Sessions should follow the following format:

  • Brief Update and Mood Check
  • Bridge from Previous Session
  • Set Agenda
  • Review Homework
  • Potential supporting exercises (see below)
  • Final Summary
  • Assign Homework
  • Feedback

 

Session-by-Session Information: Objectives, Possible Strategies, and Suggested Homework Assignments

            Note: The therapist should attempt to move sequentially through the below list of components while recognizing that to maximize the fit to the client’s issues, it may be necessary to alter the exact sequence of components, as well as omit or revisit certain components.  It is to be expected that some of these components would be discussed over multiple sessions.

 

Session 1

  • Objectives: The objective of this session is to fully understand the nature of the client’s anxiety as well as to do an inventory of the previous coping strategies used to deal with the anxiety. The therapist should also aim to induce Creative Hopelessness by focusing on the relative failure of past attempts and the possibility that control is an “unworkable system.”
  • Potential supporting exercises:
    • Solicit basic goals from the client
    • Solicit past attempt to cope with anxiety
    • Treatment Model Handout
    • Digging out of the Hole Metaphor (text p. 101-104)
    • Introduce the idea of the “unworkable system”
    • Option to continue with “control as the problem” (time permitting)
  • Homework:
    • What Have I Given Up for Anxiety? Handout
    • Mindful Worry Sheet (MWS)

 

Session 2

  • Objectives: The objective of this session is to elaborate on the prior session’s conclusion that control strategies are an “unworkable system” and to use experiential exercises to test the efficacy of control strategies. Therapist should introduce the idea that “control is the problem, not the solution.”  To the extent that it applies, help the client appreciate worry as a strategy that promotes the avoidance of imagery that is associated with more intensive negative affect.
  • Potential supporting exercises:
    • Control as the problem/Control of private events (manual p.46)
    • ACT conceptualization of GAD (Eifert & Forsyth, 2005, p. 27)
    • Polygraph Metaphor (text p. 123)
    • Chocolate Cake Exercise (text p. 124)
    • Tug of War with Monster (text p. 109)
    • Option to continue with Willingness (time permitting)
  • Homework:
    • Mindful Worry Sheet (MWS) Handout

 

 

Session 3

  • Objectives: The objective of this session is to continue to drawn on the client’s experience to strengthen the recognition that “control is the problem,” that worry is an avoidance strategy, and to introduce Willingness as an alternative to control. Finally, the therapist should introduce and establish an emphasis on the importance of cultivating mindfulness.
  • Potential supporting exercises:
    • Willingness as an alternative to control: Two Scales Metaphor (manual p.62)
    • Willingness Handout
    • Clear vs. Muddy Emotions
    • Unwanted Visitor (a.k.a. Joe the Bum (manual p.65)
    • Introduce Mindfulness with Mindful Breathing exercise (manual p. 24)
    • Review Treatment Model Handout
  • Homework:
    • Read “What is Mindfulness?” Handout
    • Function of Worry Handout (if appropriate)
    • Mindfulness Breathing Exercise Handout with assignment for practice
    • Practicing Mindfulness Handout
    • Mindful Worry Sheet (MWS)

 

Session 4

  • Objectives:  The objective of this session is to build on an orientation to developing mindfulness skills, as an alternative to worrying as an avoidance strategy. The concept of Defusion should also be introduced. 
  • Potential supporting exercises:
    • (Start with) Mindfulness Breathing Exercise (manual p.27)
    • Leaves on a Stream (Mindfulness) (manual p. 90)
    • Milk, Milk, Milk Exercise (text p. 154)
  • Homework:
    • Continued Mindfulness practice
    • Mindful Worry Sheet (MWS)

 

 

 

 

Session 5

  • Objective: The objective of this session is to introduce the importance of values and how they are distinct from goals, as well as to establish some simple behavioral goals in the service of the identified values.
  • Potential supporting exercises:
    • (Start with) a Mindfulness Exercise**
    • Introduction to values ( manual  p.53)
    • Discuss relationship between goals and values
    • Choosing values: Choices vs. Judgments/Decisions  (manual p.70)
    • Identification of values: Tombstone Exercise (Handout)
    • Identify a valued action (behavioral goal) to perform this week
  • Homework:
    • Values Identification Worksheet
    • Mindfulness Practice
    • Performance of identified valued action

 

**any of a number of Mindfulness exercises can be chosen.  They include Leaves on a Stream, Breathing Exercise, Mindfulness of Sounds, etc. See pages 88-95 in the treatment manual.

 

Session 6

  • Objectives: The objective of this session is to continue to build an orientation to mindfulness and to introduce additional practical ways to foster defusion.
  • Potential supporting exercises
    • (Start with) Mindfulness Breathing Exercise (manual p.27)
    • Skills of Mindfulness Handout
    •  “And” versus “but” (manual p.78)
    • “I’m having the thought that . . .”
    • Raisin Mindfulness exercise (manual p.27)
  • Homework:
    • Mindfulness Practice
    • Mindful Worry Sheet (MWS)
    • Identify a valued action (behavioral goal) to perform this week

 

Session 7

  • Objectives: The objective of this session is to consider the functions of emotions, our habit of emotional avoidance, and the distinction between Clear vs. Muddy emotions.
  • Potential supporting exercises
    • (Start with) Mindfulness of Sounds exercise (manual p.35)
    • The Function of Emotions Handout and discussion
    • Control of Emotion Cycle Handout
    • Emotional Avoidance (Hot Stove Analogy) (manual p.35)
    • Clear versus Muddy emotions (manual p.39)
  • Homework
    • Mindfulness Practice
    • Identify a valued action (behavioral goal) to perform this week

 

 

Session 8

  • Objectives: The objective of this session is to introduce the distinction between the observer and conceptualized selves, and to recognize the connection between self-conceptualizations and anxiety and worry.
  • Potential supporting exercises:
    • (Start with) a Mindfulness Exercise
    • Discussion of conceptualized vs. observer self (text p.184)
    • Observer Self Exercise (manual p.60)
    • Identify a valued action (behavioral goal) to perform this week
  • Homework
    • Mindfulness Practice
    • Performance of identified valued action

 

Session 9

  • Objectives: The objective of the session is to introduce the idea of commitment as a means to move towards identified values and to strengthen choices to achieve identified goals.  This serves to undermine the perpetuation of anxious worry and avoidance.
  • Potential supporting exercises
    • (Start with) a Mindfulness Exercise
    • Coke or Pepsi Exercise (manual p.70)
    • Commitment as a process (manual p.71)
    • Identification of actions steps (smaller goals in the service of the larger ones)
    • Gardening Metaphor (manual p.72)
    • Barriers to goals and willingness to accept them: Bubble in the Road Metaphor (manual p.72)
    • Passengers on the Bus (manual p.73)
    • Identify a valued action (behavioral goal) to perform this week
  • Homework:
    • Mindfulness Practice
    • Performance of identified valued action

 

Session 10 (and subsequent sessions that are not prior to termination)

Objectives

  • Continue to emphasize the components most relevant to specific client issues.
  • Homework should continue to feature behavioral goals in the form of making commitments to specific actions that are inspired by the client’s larger goals and values.
  • Continue to emphasize mindfulness skills by assigning it as homework and by beginning each session with a short mindfulness exercise.
  • Additional Metaphors/Exercises (to be used to the extent that they are useful):
    • All-or-nothing nature of Willingness: Jump Exercise (text p.240)
    • “Don’t think, just hit”
    • Descriptions vs. evaluations (manual p.77)
    • Labeling thoughts, feelings, emotions (manual p.78)
    • Reasons as causes(manual p.78)
    • FEAR algorithm for identification of barriers
    • ACT algorithm for committed action

 

Session 11

  • Objectives:
    • To teach the client to be his or her own therapist.
    • To maximize the likelihood that the client will continue to apply skills learned in therapy after termination.
    • To differentiate between a lapse and a relapse
    • To normalize low to moderate levels of worry and anxiety
    • To address client’s concerns about termination, if applicable.
  • Potential supporting exercises:
    • Path Up the Mountain Metaphor (text p.222)
    • Relapse Prevention
    • Preparation for Termination
  • Homework:
    • Develop a post-treatment plan
    • Record goals for self (i.e., in 1 month, 6 months, 1 year)
    • Identify a valued action (behavioral goal) to perform this week

 

 

Session 12

  • Objectives:
    • To reflect on progress made and the client’s continuing goals.
  • Potential supporting exercises:
    • Relapse Prevention
    • Review and refine post-treatment plan
    • Treatment Review Handout
    • Treatment Summary Handout
    • Termination

 

 

 

References

 

Eifert, G. & Forsyth, J. (2005). Acceptance and Commitment Therapy for Anxiety Disorders. Oakland: New Harbinger.

 

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. New York: Guilford Press.

 

Orsillo, S. & Roemer, E. Treatment Manual for Generalized Anxiety Disorder, Unpublished.

 

 

 

 

Appendix

 

Metaphor Description Prompts

 

Bubble in the Road Metaphor (manual p. 72) - A metaphor for barriers to goals and willingness to accept them:

 

Digging out of the Hole (manual p.101) – The client has fallen down into a hole and has only a shovel.

 

Clear vs. Muddy Emotions (manual p.40) – Clear Emotions are a product of living, while Muddy Emotions are our response to/reaction to Clear Emotions.

 

Funeral Exercise/Tombstone Exercise - two exercises that facilitate the identification of values and contrast a value-directed life with one driven by avoidance

 

Gardening Metaphor (manual p.72) – A metaphor about how lack of commitment and continually beginning again undermines our movement in a valued direction.

 

Jump (manual p.240) – The nature of Willingness requires 100% commitment, but can choose when and where you are going to be willing.

 

Leaves on a Stream (Mindfulness) (manual p.90) – A metaphor to facilitate mindfulness meditation practice.

 

Milk, Milk, Milk Exercise (text p.154) – Excessive repetition of language decontextualizes the words and reminds us that words as descriptions are qualitatively different from experiences.

 

Observer Exercise (manual p.60) – The client is asked to share three different memories from different phases of life and in which one, to consider who was noticing how the client was feeling in that moment. Contrast with the conceptualized self.

 

Passengers on the Bus (manual p.73) – The image of driving a bus full of rowdy passengers remind us of the cost of trying to control distressing private events and the benefits  of choosing to focus on a chosen action.

 

Polygraph Metaphor (text p.123) – The idea of being attached to a sensitive instrument that monitors anxiety helps the patient appreciate the limitations of the control agenda.

 

Tug of War with Monster (text p.109) – An endless battle with a monster of distress reveals the hopelessness of the situation and points toward the possibility of a creative alternative.

 

Path Up the Mountain Metaphor (text p.222) – This metaphor involves seeing one’s path up a mountain form the perspective of someone watching from afar on a different mountain.

 

Two Scales Metaphor (manual p.62) – We have two scales, anxiety/depression and Willingness, but we only have control of the latter.

 

Unwanted Visitor (a.k.a. Joe the Bum Metaphor) (manual p.65; text p.239) – This metaphor in which the client is hosting a party reminds us of the costs of being unwilling to experience distressful private events.

 

 

 

 

Handouts

 

Control of Emotion Cycle Handout

Daily Experiences Diary

Function of Emotions Handout

Function of Worry Handout (if appropriate)

Mindful Worry Sheet (MWS)

Mindfulness Breathing Exercise Handout

Mindfulness Practice

Practicing Mindfulness Handout

Skills of Mindfulness Handout

Tombstone Exercise

Treatment Model

Treatment Review

Treatment Summary

Valued Directions Worksheet

What Have I Given Up for Anxiety?

“What is Mindfulness?” Handout

Willingness Handout

 

 

 

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درمان پذیرش و تعهد برای درمان اضطراب فراگیر

درمان تعهد برای درمان اضطراب فراگیر

درمان پذیرش برای درمان اضطراب فراگیر

درمان اضطراب فراگیر

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