“This intensely practical book offers a cutting-edge evidence-

based framework for mental health professionals seeking to more

effectively address the myriad interpersonal problems that
individuals seeking psychotherapy face in their daily lives. It is
the first book of its type to bridge the more cognitive notions of
schemas with newer mindfulness and acceptance-based behavior
therapies such as acceptance and commitment therapy. The
authors know both worlds intimately, and offer a straightforward
approach that gets to the heart of patterns of unhelpful
interpersonal behavior that ultimately damage significant social
bonds. The book is full of practical exercises, worksheets, and
even a full-length protocol outlining its use in either an individual
or group therapy format. This book is a must-read for any mental
health practitioner who takes seriously the significant social and
interpersonal problems faced by those they serve.”
—John P. Forsyth, PhD, professor of psychology at
University at Albany, SUNY, and director of its
anxiety disorders research program

“Acceptance and Commitment Therapy for Interpersonal

Problems is a user-friendly guide to helping your clients employ
ACT to manage the pain and suffering caused by unhelpful
schemas that contribute to the relationship distress that often
accompanies the personal disorders they bring to their sessions
with you. This book will guide you through a step-by-step process
for helping your clients accept schema-related pain in the service
of values-based interpersonal behavior. Highly recommended.”
—Richard Blonna, EdD, author of Stress Less, Live
More

“Interpersonal difficulties are a common focus of clinical work,

either as a primary presenting problem or one that further
complicates other issues that clients bring with them to therapy.
This book skillfully integrates schema theory with acceptance and
commitment therapy. Matthew McKay, Avigail Lev, and Michelle
Skeen guide the reader through a systematic program
emphasizing mindfulness and compassionate acceptance of
thoughts, feelings, and urges that typically result in interpersonal
difficulties, along with the clarification of personal values to
inform alternative ways of relating to others. Numerous handouts
and forms throughout, as well as an appendix with a session-by-
session protocol, provide an easy-to-follow set of empirically-
supported guidelines. This book should be a welcome addition to
the library of all mental health professionals who struggle in
working with clients who find their relationships with loved ones,
friends, and coworkers more often a source of psychological pain
than fulfillment.”
—Robert D. Zettle, PhD, professor of psychology at
Wichita State University and the author of ACT for
Depression

“Mental health professionals interested in new horizons in

evidence-based treatments will find this book to be a valuable
first step in the direction of integrating acceptance and
commitment therapy into their work. This book offers a unique
journey through the ACT material by integrating the vernacular of
traditional cognitive behavior therapy. The authors dare ACT
therapists to broaden the scope of their conceptualizations while
challenging CBT therapists to apply mindfulness and acceptance
to their toolbox of interventions.”
—D.J. Moran, PhD, BCBA-D, founder of Pickslyde
Consulting and the MidAmerican Psychological
Institute

“While chronic interpersonal problems are often the most difficult

to address clinically, this book provides new hope for the
clinician. It is simple, practical, sound, and evidence-based.”
 —Kirk Strosahl, PhD, co-founder of acceptance and
commitment therapy and coauthor of The
Mindfulness and Acceptance Workbook for
Depression and Brief Interventions for Radical
Change

“Over the years, different therapy approaches have attempted to

help clients struggling with interpersonal problems. Despite
showing some benefits, none of these approaches made a
significant difference in these clients’ lives. Finally, ACT for
Interpersonal Disorders offers readers an alternative that is not
only innovative, but also based in research. This book sets a gold
standard for how to integrate ACT and schema therapy and shows
us step by step how to make real changes in the lives of clients
struggling with their relationship to their own pain and
relationships with the people they care about.”
—Patricia Zurita Ona, PsyD, clinical supervisor at the
Berkeley Cognitive Behavioral Therapy Clinic and
the Wright Institute’s behavioral medicine training
program

“McKay, Lev, and Skeen present a successful, innovative

combination of ACT and a schema-based approach to help clients
with interpersonal relationship problems gain more behavioral
flexibility and move beyond inflexible patterns of relating. Rather
than changing dysfunctional schemas or core beliefs, the authors
teach readers in clear, practical steps how to help clients alter the
way they relate to their thoughts so that they can choose different
responses based on their chosen values. The book is based on
long-term clinical and research experience that shows how clients
gain greater psychological flexibility through building acceptance
and defusing from unhelpful thoughts, emotions, and beliefs—
including schemas. With its many worksheets and exercises, as
well as a session-by-session treatment outline, this book is a great
resource for any therapist who wants to help clients develop less
conflict-filled, richer, and more fulfilling life.”
—Georg Eifert, PhD, professor emeritus of psychology
at Chapman University

“Relying on a storytelling clinical voice, the authors articulate an

innovative approach to applying ACT technology to interpersonal
problems using the language of schemas (e.g., abandonment,
failure) as a heuristic to identify historic thoughts, feelings, and
action urges that are sources of pain and unlikely to go away. The
book describes a step-by-step treatment approach wherein the
clients learn to recognize old moves to avoid the emotional pain
associated with these schemas and discover how to stop these
behaviors that create unnecessary interpersonal suffering. It
includes clear descriptions of interventions, with samples of
therapist-client dialogue and handouts to use with clients. The
book is based on a small randomized controlled trial in a group
setting and indeed, it includes that protocol in one of the
appendices; however, the material presented in this book could
easily be utilized in individual and couples therapy, as well.”
—Jacqueline Pistorello, PhD, coauthor of Finding Life
Beyond Trauma
 Publisher’s Note
This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold
with the understanding that the publisher is not engaged in rendering psychological, financial, legal, or other professional
services. If expert assistance or counseling is needed, the services of a competent professional should be sought.
Distributed in Canada by Raincoast Books
Copyright © 2012 by Matthew McKay, Avigail Lev, and Michelle Skeen
New Harbinger Publications, Inc.
5674 Shattuck Avenue
Oakland, CA 94609
www.newharbinger.com
Cover design by Amy Shoup; Text design by Michele Waters-Kermes; Acquired by Catharine Meyers;
Edited by Jasmine Star
All Rights Reserved
_________________________________________________________________________________
Library of Congress Cataloging-in-Publication Data
McKay, Matthew.
Acceptance and commitment therapy for interpersonal problems : using mindfulness, acceptance, and schema awareness to
change interpersonal behaviors / Matthew McKay, Avigail Lev, and Michelle Skeen.
p. cm.
Summary: “Acceptance and Commitment Therapy for Interpersonal Problems offers a complete professional protocol for treating
clients who suffer from a variety of interpersonal issues, including tendencies toward blame, withdrawal, anger, contempt,
defensiveness, and distrust. Based in acceptance and commitment therapy (ACT) and schema therapy, this approach helps clients
understand and move past their interpersonal disruptions and difficulties”-- Provided by publisher.
Includes bibliographical references and index.
ISBN 978-1-60882-289-8 (hardback) -- ISBN 978-1-60882-290-4 (pdf e-book) -- ISBN 978-1-60882-291-1 (epub)
1. Interpersonal psychotherapy. 2. Interpersonal relations. 3. Acceptance and commitment therapy. I. Lev, Avigail. II. Skeen,
Michelle. III. Title.
RC489.I55M35 2012
616.89’14--dc23
2012003631
 Contents
Foreword
INTRODUCTION
CHAPTER 1: THE CHALLENGE OF TREATING
INTERPERSONAL PROBLEMS
CHAPTER 2: INTRODUCING SCHEMAS
CHAPTER 3: UNDERSTANDING SCHEMA COPING BEHAVIORS
CHAPTER 4: CULTIVATING CREATIVE HOPELESSNESS AND
DEVELOPING MINDFULNESS SKILLS
CHAPTER 5: CLARIFYING VALUES AND COMMITTING TO
VALUES-BASED ACTION
CHAPTER 6: DEFUSING FROM THOUGHTS AND DEVELOPING
THE OBSERVER-SELF PERSPECTIVE
CHAPTER 7: CONDUCTING EXPOSURE WITH DEFUSION
CHAPTER 8: WORKING WITH SIX KEY PROCESSES
Appendix A: Schema Questionnaire
Appendix B: Research Outcomes
Appendix C: Group Protocol (Written with Koke Saavedra)
References
 Foreword
This is the first book of which I’m aware that combines ideas from
schema-focused therapy with methods from acceptance and commitment
therapy (ACT). These two treatment approaches come from different wings
of the cognitive behavioral community, which could suggest that they will
be in conflict. In the hands of these authors, that never happens.
This book approaches schemas simply as well-ingrained patterns of
thought. There is nothing in this idea that violates ACT. Schemas imply a
kind of functional theme, and the authors focus on ten patterns of particular
importance to interpersonal problems: abandonment, mistrust, deprivation,
defectiveness, alienation, incompetence, failure, entitlement, subjugation,
and hypercriticalness. Chunking patterns of thinking into larger units and
themes in this way can make it somewhat easier for the clinician to detect
larger patterns and see the possible functions for more fine-grained
thoughts. It can help the client and clinician alike see the forest and not just
the individual trees.
Building on the identification of schemas, the tested protocol presented
here brings ACT sensibilities to how schemas can be addressed effectively.
That is, schemas, once identified, are addressed largely through ACT
methods. The authors make that task easy by thinking about schemas in a
functional sense. Just as in traditional ACT, which holds that fusion with
thoughts leads fairly directly to experiential avoidance, in the schema-
focused perspective described in this book, coping with schemas leads
fairly directly to avoidant forms of adjustment. The functions of schema
coping behaviors are to escape from or avoid the emotional pain that is
connected to a particular pattern of thinking. That helps turn schemas into
themes to be used to detect unhelpful patterns of avoidance and their
history. It’s a useful idea that is put to good use in this book.
One reason to take a more schema-focused approach in the domain of
interpersonal problems is that such problems present themselves in a
bewildering variety of forms. It is very easy to get caught up in content—in
the details of the interpersonal stories and difficulties that make up the
psychological aspect of the social world. Everyone has relationship
difficulties from time to time, but this book is focused on recurring
difficulties in relationships based on chronically dysfunctional styles of
interacting. When dealing with problems of that kind, the larger patterns are
more important than the details of a given instance.
Many years ago, language researchers determined that human language
has a limited set of analytic dimensions; you could summarize the myriad
evaluative themes into just three polar dimensions (good/bad, strong/weak,
and fast/slow). Schemas can help in much the same way. If you can avoid
reifying them, or turning them into causes, schemas can help focus clients
and clinicians alike on a small set of themes to apply to the many details.
The act of looking for larger patterns helps clients take a more defused and
mindful look at their own behavior, and it can empower the search for ways
to create new forms of adjustment. It helps clients step back and ask “What
am I up to here?” and “What are the larger patterns of relationship that I am
building in this moment?” That step—of backing up and looking for larger
patterns—is a powerful ally of change. It is not by accident that this book
uses ACT methods in service of this process, because the process is entirely
ACT consistent.
The protocol in this book constantly directs the clinician’s attention
toward the function of thought and emotion, and the construction of more
effective behavioral patterns. It is very much to the credit of the authors that
the protocol itself has been tested so we can say with some confidence that
it can be of help in working with interpersonal problems. Detailed
descriptions of interventions are provided, and scripts help readers envision
when they might be used.
There are a limited number of approaches available for interpersonal
problems. It is still early, but I believe this book adds another method to that
list of approaches. Given how pervasive and destructive interpersonal
problems can be, it has not arrived a moment too soon.
—Steven C. Hayes Foundation Professor, University of Nevada
 Introduction
Clients present with interpersonal problems that often occur across
multiple relationships and life domains (friends, work, family, partner, and
so on). Pervasive interpersonal problems can thus reach a level that could
be seen as an interpersonal disorder, contributing to failed relationships,
social isolation, depression, and work dysfunction.
Clients struggling with interpersonal problems are frequent visitors to
therapists’ offices. At the Berkeley Cognitive Behavioral Therapy Clinic,
for example, more than 50 percent of our intakes identify significant
recurring interpersonal difficulties. The majority of clients presenting with
depression, trauma, anxiety, and Axis II disorders report interpersonal
problems in more than one important relationship. Colleagues across the
country report similar data.
Clearly, interpersonal problems are pervasive in the population seeking
psychotherapy. Interpersonal problems destroy relationships and trigger
extraordinary suffering, both for those affected and for those to whom they
relate. Yet for all the pain these problems create, few systems of
psychotherapy directly target the interpersonal behavior that drives the
problem, and there is little research addressing what treatments effectively
change disordered interpersonal functioning (this is discussed in chapter 1).
Therefore, the purpose of this book is to offer a treatment that targets
relationship-damaging behavior and also has some empirical support (see
chapter 1 and appendix B for information on a randomized controlled trial
of this therapy in a group setting).
Given that you are reading this book, you probably have clients who
struggle interpersonally and repeatedly engage in damaging responses to
relational stress. You may also have clients whose primary concern is
anxiety, depression, or trauma but who have a history of broken
relationships. Among these clients, you may have found that treatment
targeting only the emotional problems doesn’t help them reach high levels
of well-being. The approach outlined in this book—a schema formulation
with mindfulness- and acceptance-based interventions—may provide you
new tools to effectively treat these interpersonal problems.
 In chapter 1, we briefly discuss current treatments for interpersonal
problems, reviewing their effectiveness and shortcomings and explaining
why we believe the novel combination of ACT and schema theory is a more
advantageous approach. In chapters 2 and 3, we outline how to begin this
approach by introducing clients to the concepts of schemas and schema
coping behaviors and helping them identify their schemas, triggers, and
problematic coping behaviors. Clients also assess how these have impacted
their lives and relationships. Chapters 4 through 7 focus on ACT processes:
cultivating creative hopelessness, developing mindfulness skills, clarifying
values, committing to values-based behavior, cognitive defusion,
developing the observer-self perspective, and emotion exposure. The
processes and approaches in these chapters are employed to help clients
identify how they would rather conduct themselves in relationships and to
provide motivation for undertaking the challenging work of changing long-
standing patterns of behavior. In chapter 8, we discuss common issues that
arise when conducting this therapy and provide suggestions on how to deal
with those issues.
The book also contains three appendices. Appendix A is an example of
the type of schema questionnaire you might administer before treatment to
help identify clients’ key schemas. (We recommend the Young Schema
Questionnaire, which you can purchase at www.schematherapy.com). Note
that Appendix B outlines the results of research on the effectiveness of the
approach used in this book. Appendix C provides a detailed, session-by-
session protocol for conducting ACT for interpersonal problems in a group
setting. This group protocol is adapted from the protocol used in the study
summarized in appendix B.
You’ll note that there are some differences in the order in which various
techniques are presented in the main text versus the group protocol in
appendix C. In appendix C the organization is strictly chronological,
whereas in the main text, topics are organized more thematically. This
thematic organization allows us to present similar techniques and concepts
together for clarity’s sake. In practice, you might use techniques from
several of the chapters in any given session in response to what’s going on
in the room. For this reason, we recommend that you read through the entire
book—or at least through chapter 8—before utilizing this approach with
clients.
 Note that we’ve designed appendix C to be a stand-alone guide to
treatment. In theory, you could photocopy this section of the book and use it
as your sole reference when conducting group therapy. However, we
recommend that you first read chapters 1 through 8 in their entirety so
you’ll have a deeper understanding of the approach and the theory behind it.
This will allow you to offer group therapy more flexibly, tailoring it to the
needs of group members or situations that arise in session.
Feel free to photocopy the handouts and worksheets in this book for use
in your practice. However, do note that these materials are protected by
copyright, so please seek permission to use them in published material. The
exception is the questionnaire in appendix A. It is provided solely as an
example. If you wish to use a similar questionnaire in your practice, please
visit schematherapy.com, where you can purchase the most current version
of Jeffrey Young’s questionnaire for research or clinical use.
 Chapter 1

The Challenge of Treating Interpersonal

Problems
The currently available treatments for interpersonal problems are largely
inadequate. They either fail to target and change the maladaptive coping
behavior, fail to address the underlying (transdiagnostic) causes of
interpersonal problems, or fail to provide techniques for tolerating
interpersonal distress. A more effective treatment is needed. This book
offers a new treatment for chronic interpersonal problems, one that both
targets key components of the problem and has research support.
Acceptance and commitment therapy (ACT) has significant empirical
support for effectiveness with emotional disorders (Eifert & Forsyth, 2005;
Saavedra, 2008; Zettle, 2007) and multiple psychological and behavioral
problems (Hayes & Smith, 2005). Now, for the first time, ACT has been
combined with a schema therapy formulation (Young, Klosko, & Weishaar,
2003) in an approach that has been successfully applied to interpersonal
problems. We will briefly review the research evidence for its effectiveness
later in this chapter and discuss it more fully in appendix B. For now we’ll
simply say that the outcome data is promising.

Defining Interpersonal Problems

The term “interpersonal problems” refers to recurring difficulties that
clients have in relationships due to specific maladaptive responses and
coping behaviors that result in a dysfunctional interactive style. These
responses and behaviors, learned in childhood, may include withdrawing,
blaming, clinging, attacking, or surrendering. They may have served an
adaptive function at some point in life, but in adult relationships they tend
to be problematic. For example, it may have been adaptive for a child to
avoid an angry parent, surrender to a domineering parent, or withdraw from
a detached parent, but continuing to use these coping behaviors in current
relationships leads to further pain and suffering.
 People often learn these coping behaviors by watching their parents and
other family members deal with pain. They may have had role models who
got angry and went on the attack when they were hurt, manipulated others
to meet their own needs, or became overly compliant in order to avoid
abandonment.
Not all coping strategies are learned through modeling. When people
get triggered in relationships, they may stumble on a response that
somehow gives them a little temporary relief and then stick with that, doing
it again and again in similar situations. These coping behaviors produce
short-term relief in the moment, but in the long run they damage
relationships. Interactions stop feeling good, and after a while others tend to
harden or withdraw. This process—trading short-term relief for long-term
interpersonal difficulties—is the source of recurring interpersonal problems.

Three Aspects of Maladaptive Coping Behaviors

The patterns of maladaptive coping behavior that arise as a result of efforts
to manage interpersonal needs and stressors typically have three key
aspects:

They are inflexible.

They are based on pathogenic beliefs (schemas) about self and

others in relationships.

They are driven by experiential avoidance.

Inflexible
Patterns of maladaptive coping behaviors in relationships are inflexible
because they were formed during early childhood experiences and continue
to be reinforced in adult life (Levenson, 1995; Sullivan, 1955/2003). They
tend to be inflexible and pervasive regardless of negative consequences and
also tend to create a self-fulfilling prophecy. They aren’t altered by negative
outcomes because they are effective, temporarily, at allaying anxiety and
pain through negative reinforcement.
Based on Pathogenic Beliefs
Jeffrey Young (1999) defines schemas as deeply held cognitive
structures and core beliefs about oneself and others, including particular
themes and expectations about interpersonal relationships. Schemas are
deeply ingrained because they aid in understanding and organizing one’s
world and one’s relationships. They create a sense of predictability and
safety. Further, it has been said “early maladaptive schemas are…at the core
of personality pathology and psychological distress, in particular
personality disorders and chronic interpersonal difficulties” (Nordahl,
Holthe, & Haugum, 2005, p. 142).
People’s pathogenic beliefs and expectations in relationships compel
them to continue to use the same schema-avoidant strategies (E. Cohen,
2002; Flasher, 2000; Levenson, 2010; Safran & Segal, 1996). For example,
people with an abandonment and instability schema have an expectation
that they will ultimately be abandoned in relationships. This bias leads to
distortions and selective attention toward environmental cues of perceived
abandonment. When an individual’s schema gets triggered, it elicits
particular thoughts, feelings, sensations, and behaviors that are connected to
the schema. (In this book, we’ll use the term “schema coping behaviors”
(SCBs) to refer to problematic reactions that occur when schemas are
activated.) People may defend against abandonment schemas through
excessive autonomy, disconnecting, clinging, or withdrawing. These coping
behaviors are attempts to escape from or suppress the emotional pain
connected to the schema. Schemas and attempts to avoid the pain connected
to them drive patterns of maladaptive interpersonal behavior.

Driven by Experiential Avoidance

Experiential avoidance has been defined as attempts to avoid distressing
internal experiences, including thoughts, feelings, memories, sensations,
and other private events (Hayes, Strosahl, & Wilson, 1999). Experiential
avoidance occurs when people are unwilling to experience such private
events and therefore attempt to escape or control these experiences, even if
doing so creates more harm in the long run (Hayes & Gifford, 1997).
Control strategies may work in the external environment; for example, if
you’re thirsty you can get some water. However, efforts to control internal
experiences are often unsuccessful and can result in maladaptive behavior.
A wide range of research indicates that many forms of psychopathology can
be conceptualized as maladaptive strategies aimed at avoiding or
eliminating particular thoughts, memories, emotions, or other distressing
internal experiences (Chawla & Ostafin, 2007; Gamez, 2009; Hayes,
Wilson, Gifford, Follette, & Strosahl, 1996). Therefore, targeting
experiential avoidance strategies in relationships should be a fundamental
component in the treatment of interpersonal problems.

Criteria for Treating Interpersonal Problems

Given the understanding of interpersonal problems outlined above,
treatment must target and change maladaptive coping patterns. To do so
effectively it must address all three aspects of these behaviors:

To address and improve behavioral flexibility, it should encourage a

broader repertoire of behavioral responses and help clients develop
this repertoire. Such flexibility must be based on outcomes and
consequences and include an assessment of the workability of new
and old behaviors.

It must address schemas and how they influence clients’

interpersonal behaviors.

To target avoidance strategies, it should provide motivation and

methods for tolerating the schema-driven emotional pain that
spawns avoidant behaviors.

Current Treatments
Currently, several different treatment approaches are commonly used for
interpersonal problems:

Interpersonal psychotherapy: a time-limited form of

psychotherapy, originally developed for the treatment of depression,
that focuses on maladaptive relational patterns
 Transference-focused psychotherapy: a form of psychoanalytic
psychotherapy, developed by Otto Kernberg, that treats borderline
personality disorder using transference-based interpretations

Time-limited dynamic psychotherapy: a short-term treatment for

chronic interpersonal problems that targets dysfunctional styles of
relating

Dialectical behavior therapy: a behavioral treatment for borderline

personality disorder with accompanying suicidal and parasuicidal
behaviors that teaches four key skills (emotion regulation,
mindfulness, distress tolerance, and interpersonal effectiveness)

Schema-focused therapy: a cognitive behavioral therapy treatment

targeting borderline and narcissistic personality disorders that
identifies core maladaptive schemas and schema-avoidance
behaviors that damage relationships

Unfortunately, all of these approaches have disadvantages. Although

they do target maladaptive relational patterns, there is mixed empirical
evidence for their effectiveness in changing interpersonal behavior.
Research findings regarding the clinical impact on clients’ interpersonal
interactions are ambiguous. Dialectical behavior therapy, for example, has
significant research support for reducing suicidal and parasuicidal behavior,
as well as days in the hospital. Oddly, however, the literature is vague on its
ability to change chronically ineffective interpersonal behavior. And while
several of the current treatments use inventories that assess borderline
personality traits, interpersonal functioning is only a subscale of these
measures.
Although there is ample evidence that all of these treatments are
effective in reducing hospitalizations, reducing frequency of parasuicidal
behaviors, and decreasing symptoms related to borderline personality
disorder, it is difficult to parse their impact on changes in interpersonal
behaviors specifically. In addition, the field suffers from a paucity of
objective measures and inventories for assessing interpersonal functioning
and behaviors in relationships.
 Moreover, each of the above therapies fails to meet one or more of the
criteria for treating interpersonal problems outlined above. Transference-
focused psychotherapy meets none of them, as it doesn’t target behavioral
flexibility, pathogenic beliefs, or experiential avoidance—and also doesn’t
target behavioral change, which is necessary for developing new responses
to replace maladaptive coping patterns. Interpersonal psychotherapy fails to
address pathogenic beliefs and also doesn’t provide methodologies aimed at
experiential avoidance or tolerating emotional pain. Dialectical behavior
therapy doesn’t address pathogenic beliefs, and schema-focused therapy
doesn’t provide techniques aimed at curtailing avoidance or tolerating
emotional pain. Time-limited dynamic psychotherapy is arguably the most
effective and best-targeted approach among current treatments, yet it too
doesn’t address experiential avoidance or provide clients with methods for
tolerating the emotional pain that drives maladaptive interpersonal
responses.
In summary, something new is needed that more effectively targets the
underlying factors driving chronic interpersonal problems. We believe that
the combination of ACT with a schema-based formulation is that new
approach.

An Alternative Treatment Approach

This book presents a new, acceptance-based treatment approach to
interpersonal problems that targets behavioral change (and maladaptive
coping strategies in particular) and addresses all of the criteria outlined
above:

It is designed to enhance behavioral flexibility in interpersonal

settings and is focused on workability of behavior.

It addresses the role of pathogenic beliefs, or schemas.

It specifically targets experiential avoidance by providing specific

methods for tolerating emotional pain (such as mindfulness, self-as-
context, and cognitive defusion) and, through values clarification,
provides motivation for changing avoidant behaviors.
 People with interpersonal problems are characterized by inflexible
patterns of relating and are a difficult population to treat. Given the rigidity
of these patterns, ACT appears to be a beneficial treatment approach
because it promotes psychological flexibility through building acceptance
and defusing from thoughts, emotions, and beliefs, including schemas. ACT
doesn’t attempt to change schemas and core beliefs; rather, it alters the way
people relate to them so that they can choose different responses to schema-
related pain and take steps in valued directions.
This book is based on long-term clinical and research experience that
has been gained working with clients who struggle with interpersonal
problems. The ten-week group therapy ACT protocol provided in appendix
C is supported by research conducted by Avigail Lev (2011) testing the
effectiveness of a very similar protocol used for the treatment of
interpersonal problems. The study was a randomized controlled trial that
was conducted at a community-based clinic for recovery from substance
abuse. The study’s sample consisted of forty-four male clients who were
randomly assigned to control (treatment as usual) or experimental (ACT
plus treatment as usual) conditions. (Treatment as usual was a day-
treatment recovery program that included 12-step study, relaxation training,
anger management, relapse prevention, and a host of other services.) The
major finding of the study was that the ACT group experienced significant
decreases in problematic interpersonal behaviors, as measured by the
Inventory of Interpersonal Problems (IIP). Results showed large
improvements in pre- to post-treatment measures of interpersonal problems
in both the mixed factorial ANOVA and the Cohen’s d (d = –1.23). These
findings provide strong support for the potential effectiveness of this
protocol and its ability to improve interpersonal functioning. (See appendix
B for further details about and results of this research.)

Summary
In short, none of the current treatment approaches for interpersonal
problems adequately target all aspects driving maladaptive coping
behaviors. The innovative combination of ACT with a schema-based
approach allows for a well-rounded treatment protocol that addresses all of
the essential criteria. To be clear, this is an ACT treatment. It doesn’t use
any schema therapy techniques; schemas are utilized solely for the purpose
of identifying clients’ primary pain. The goal of this approach is not to
change clients’ schemas or core beliefs; rather, the goal is to help them
accept the primary pain associated with their schemas and assist them in
improving behavioral flexibility in order to enhance values-based living.
 Chapter 2

Introducing Schemas
The treatment of interpersonal problems begins with defining early
maladaptive schemas and helping clients identify which schemas are
relevant to them and contribute to their problematic relationships. Because
this material may be unfamiliar (not to mention challenging), take your time
with it—perhaps two sessions. Then you can move on to helping clients
identify common schema triggers so they can begin to bring more mindful
awareness to these situations as they occur. Once clients are aware of how
schema-driven thoughts, emotions, and behaviors are impacting their
interpersonal interactions, they have more opportunity—and more
motivation—to change their behavior.

Understanding Schemas
A schema is a core belief that’s generated in early childhood as a result of
an individual’s experiences with parents, caregivers, siblings, and peers.
Schemas are deeply rooted cognitive structures and beliefs that help define
a person’s identity in relationship to others. As such, schemas exert a huge
influence over interpersonal behavior and are the driving force behind
interpersonal problems. Early maladaptive schemas are very powerful for a
number of reasons (Young and Klosko, 1993):

They include unconditional beliefs about who we are and what we

can expect in relationship to others and the world. They are
experienced as a priori truths and are taken for granted.

They are self-perpetuating and resistant to change because they

develop in early childhood and adolescence. They can be
experienced in the first few years of life and can therefore be
preverbal.
 They are derived from early trauma, neglect, and repeated negative
messages about the self. As a result, they form the core of self-
concept.

They are tied to high levels of distressing emotion, or schema affect.

Typically, schema affect includes fear, shame, loneliness, a sense of
emotional hunger or yearning, anger, or a combination of these.

They are activated by relevant events. For example, a failure schema

is often activated by criticism or confronting a challenging task.

They attempt to predict the future. Schemas help organize people’s

knowledge about interactions between themselves and the world. At
root, schemas are efforts to identify what will happen in every
circumstance of every relationship. Because these beliefs offer the
illusion that one can peer into the future and prepare for it, they are
extremely hard to give up.

The Role of Unmet Early Childhood Needs

Maladaptive schemas are created when early childhood core needs aren’t
met. According to Jeffrey Young (Young, 2004), six needs must be met for
children to thrive. If neglected, these needs create schemas that are
problematic for people and their interpersonal relationships.

Basic safety. Essential at birth, this need involves how children are
treated by their family or caregivers. When infants or small children
aren’t provided with a stable and safe environment, they may
develop an abandonment and instability schema, a mistrust and
abuse schema, or both.

Connection to others. When children don’t receive love, affection,

empathy, understanding, and guidance from family members or
peers, they may develop an emotional deprivation schema, a social
isolation and alienation schema, or both.

Autonomy. Essential for childhood development, autonomy allows

for healthy independence and separation from parents. When
 children aren’t taught self-reliance, responsibility, and good
judgment, they are likely to develop a dependence and
incompetence schema or a vulnerability schema. (Vulnerability isn’t
one of the ten schemas included in this treatment protocol.)

Self-esteem. When children are loved, accepted, and respected, they

develop self-esteem. When family and peer support are absent,
children may develop a defectiveness and shame schema, a failure
schema, or both.

Self-expression. In a nurturing environment, children are

encouraged to express their needs and desires. When this self-
expression is discouraged, children are made to feel that their needs
and feelings matter less than those of their parents. Often these
children are punished and made to feel “less than.” When self-
expression isn’t encouraged and supported, children may develop a
subjugation schema or an unrelenting standards and
hypercriticalness schema.

Realistic limits. When children are raised in an environment that

encourages responsibility, self-control, self-discipline, and respect
for others, they learn to operate within realistic limits. When parents
are permissive and overly indulgent, children grow up without
understanding the need to consider other people before acting. In the
absence of realistic limits, children may develop an entitlement
schema.

Explaining Schemas to Clients

You can either explain to clients the properties of schemas as outlined in the
handout Understanding Early Maladaptive Schemas, or you can give them
the handout to read.

Understanding Early Maladaptive Schemas

 A maladaptive schema is essentially a belief about yourself and your relationship to
the world. It creates a feeling that something is wrong with you, your relationships, or
the world at large. Schemas are formed in childhood and develop as a result of
ongoing dysfunctional experiences with parents, siblings, and peers during childhood,
and they continue to grow as children try to make sense of their experience and avoid
further pain. Schemas come from repeated toxic messages that we get about
ourselves from our early experiences (for example, “You’re bad” or “You can’t do
anything right”) or from specific traumatic events. Once a schema is formed, it’s
extremely stable and becomes an enduring pattern that is repeated throughout your
life.

Schemas are like sunglasses that distort all of your experiences. They color the way
you see things, and they make assumptions and predictions that tell you the schema
is true or will turn out to be true. Schemas formed during childhood are triggered
repeatedly throughout your adult life. Common triggers include stressful interpersonal
events and difficult thoughts and feelings. Once a schema is triggered, it brings up
powerful automatic thoughts and feelings about yourself that can lead to depression,
panic, loneliness, anger, conflict, inadequate work performance, addiction, and poor
decision making. Schemas interfere with your ability to feel safe in relationships, your
ability to get your needs met, and your ability to meet the needs of others.

Characteristics of Early Maladaptive Schemas

They are experienced as self-evident truths about yourself or your environment.

They are self-perpetuating and resistant to change.

They seem to predict the future, particularly what will happen in relationships. And
because they create the illusion that you can see what’s coming and prepare
accordingly, they are extremely difficult to give up.

They’re usually triggered by stressful events, typically something painful in a

relationship that activates old beliefs about yourself.

They are always accompanied by high levels of emotion, such as shame, fear, hurt,
or despair.

Identifying Clients’ Schemas

There are ten schemas associated with interpersonal problems. Each of
these core beliefs has the capacity to disrupt and damage interpersonal
interactions. Most clients have more than one schema influencing
relationships, and several schemas may work in concert to create significant
distress. For example, a defectiveness and shame schema often shows up
with an abandonment and instability schema, so the belief that one is
unlovable ends up driving the expectation that one will be rejected. You can
use the descriptions in the Ten Key Schemas handout to explain these
schemas to clients. We also recommend giving them the handout to study
and refer to in the weeks to come.

Ten Key Schemas

Psychologist Jeffrey Young has identified eighteen early maladaptive schemas. Ten of
these schemas have significant relevance to interpersonal relationships. A schema is
a core belief. Core beliefs define who we are and direct how we live our lives. They
create the internal monologue that characterizes the thoughts, assumptions, and
interpretations that inform each person’s individual worldview. When a schema is
activated, it produces intense emotions. Identifying your schemas and examining how
they impact your life and your interactions with others is essential to making positive
changes in your relationships. Study this list of the ten schemas relevant to problems
in interpersonal relationships and keep it handy so you can identify which schemas
are affecting your interactions:

Abandonment and instability: the belief that significant people in your life are
unstable or unreliable

Mistrust and abuse: the expectation that you will be harmed through abuse or
neglect

Emotional deprivation: the expectation that your needs for emotional support
won’t be met, which may take several forms:

Deprivation of nurturance: the absence of attention

Deprivation of empathy: the absence of understanding

Deprivation of protection: the absence of guidance

 Defectiveness and shame: the belief that you are defective, inferior, or unlovable

Social isolation and alienation: the belief that you don’t belong to a group, are
isolated, or are radically different from others

Dependence and incompetence: the belief that you are incapable or helpless and
require significant assistance from others, that you cannot survive without a certain
person, or both

Failure: the belief that you are inadequate or incompetent and will ultimately fail

Entitlement: the belief that you deserve privileges and are superior to others

Subjugation: voluntarily meeting the needs of others at the expense of your own
needs, submitting to others to avoid real or perceived consequences, or
surrendering control to others due to real or perceived coercion

Unrelenting standards and hypercriticalness: the belief that you must meet very
high internalized standards to avoid criticism, leading to impairment in such areas
of life as pleasure, health, and satisfying relationships

Schema Affect
As mentioned earlier, each schema is associated with one or more painful
emotional states. Once a schema is triggered by interpersonal events, the
relevant schema affect immediately shows up and begins influencing the
person’s behavior. The following table identifies the typical affects for each
of the ten schemas.
 The emotions associated with schemas are so painful that people are
often motivated to do anything to cope with or try to avoid them. We’ll
examine this in detail in chapter 3.

Assessing Schemas
We recommend three approaches to identifying early maladaptive schemas:

Having the client fill out a schema questionnaire, such as the Young
Schema Questionnaire

Reviewing thought logs filled out by the client

Using imagery to trigger and identify schemas

Schema Questionnaires
The Young Schema Questionnaire has been widely used to identify the
eighteen early maladaptive schemas. In appendix A, we’ve adapted the
Young Schema Questionnaire, with the permission and assistance of Jeffrey
Young, PhD, to specifically identify the ten schemas that are relevant to
interpersonal problems. Note that the version in appendix A is just for
reference. If you wish to use a similar questionnaire in your practice, please
visit schematherapy.com, where you can purchase the most current version
of Jeffrey Young’s questionnaire for research or clinical use.

Thought Logs
A simple thought log can be a gateway to understanding clients’
schemas. Over a period of one to two weeks, have clients keep a record of
their thoughts using the Thought Log. Instruct them to use the log after
experiencing strong emotional reactions, such as sadness, anxiety, shame, or
anger, and ask that they record all significant thoughts experienced during
the period of high affect, describing triggering situations in the left-hand
column, emotional reactions in the middle column, and key automatic
thoughts in the right-hand column.
When you review the thought log, choose several thoughts that appear
to be related to schemas. Then use the downward arrow technique to probe
whether thoughts indicate operative schemas. In this technique, you’d ask,
“If [the thought] is true, what does that mean about you?” Encourage the
client to answer in terms of thoughts and beliefs, not feelings. Keep asking
this key question about each successive thought or belief until the client
describes a thought or belief that fits one of the schemas. Here’s an example
dialogue:
Therapist: Your thought log includes a thought I want to explore with you.
When your daughter resisted doing her homework with you, you
thought, “I can’t stand this.” If it were true that you can’t stand
this, what would it mean about you?
Client: It means I can’t deal with her…can’t deal with her resistance, the
way she just ignores what I want her to do.
Therapist: And if it’s true that she resists you and ignores what you want
her to do, what does that mean about you?
Client: It means I’m a screwed-up parent—that I don’t know what I’m
doing.
Therapist: And if it’s true that you don’t know what you’re doing as a
parent, what does that mean about you?
Client: It means I’m incompetent. I screw up everything that matters to me.
Notice that it doesn’t take long to get down to the schema that this client
is struggling with: failure. If you use the downward arrow technique to
inquire about what a particular thought means about the client, you’ll
eventually arrive at the underlying core belief—and schema—driving the
thought.

Imagery
To use imagery to trigger and identify schemas, start by identifying a
recent situation that created high affect and might be related to a schema.
Ask clients to visualize the scene, noticing what they saw, heard, and felt
(both physically and emotionally). When they are sufficiently immersed in
the scene to experience some affect, ask these questions:

Who are you in the scene?

What does viewing this scene make you feel about yourself?
 In this scene, what do you fear will happen?

How does the other person see you in this scene?

What are you telling yourself during this scene?

The answers to these questions often provide a relatively clear

indication of which schema is involved.

Giving Feedback to Clients

Whether you use a schema questionnaire, thought logs and the downward
arrow technique, or imagery, the assessment process will help you identify
one or more key schemas that are driving clients’ interpersonal problems.
Then you can use the Ten Key Schemas handout from earlier in this chapter
to define and discuss relevant schemas with clients. As you do so, verify
that clients recognize the schema-related core beliefs as part of their
thinking. Here’s an example dialogue showing how to achieve this:
Therapist: When we looked at your thought record, there was something
that came up over and over again. It was the thought that you
don’t fit anywhere—the sense that no one sees or understands
you. And when we looked at the different schemas on that list,
social isolation seemed to really fit for you—this feeling of not
belonging, of being alone even when you’re with people. Is that
feeling of not fitting in something that’s familiar? Has it shown up
at other times in your past?
Client: Yes. I felt just like that in my family. They were these loud, high-
energy people, and I always felt meek and quiet. They just ran
over me with their energy. I felt that in high school too, and in
college. I just didn’t belong to the groups around me.
Therapist: And later, in your adult life, has that also felt true?
Client: I feel like people don’t get me, almost like I’m a nonentity to them. I
feel like I’m on the outside looking in.
Therapist: So the schema of not fitting, of being somehow isolated from
others, stretches all the way from childhood to things you feel
 right now.
As you work with clients to identify their schemas, don’t be attached to
labels and descriptions from this book (or elsewhere). It’s often a good idea
to use clients’ language to describe and label their schema experience, as
illustrated in the preceding dialogue.

Helping Clients Recognize Schema Affect

Once you’ve confirmed the schema or schemas that influence clients’
interpersonal interactions, you can begin to explore schema-related affect.
To help clients link their schemas to emotions, you can ask direct questions;
for example, “When that defectiveness schema shows up, what emotion
seems to go with it?” or “When you begin to have that sense of emotional
deprivation and you think you won’t get what you need, what feeling comes
up with that?”
Clients usually have a very clear sense of the affect that arises when
their schemas are triggered. They’re well aware of the emotional pain that
suddenly wells up in those situations. As you talk about schemas, always
acknowledge the schema-related emotions that begin to hammer clients
when schemas are activated. It’s important to recognize and validate clients’
emotional state so that you can work together to tackle the schema-driven
affect and maladaptive coping behavior.

Schema Triggers
Virtually any interpersonal situation can potentially trigger schemas and
schema affect. Once clients are aware of their schemas and the emotional
impact of those schemas, you can work on identifying the interpersonal
situations that most typically trigger schemas. You can explain these
situations to clients as outlined in the Schema Triggers handout. We
recommend that you also give clients the handout for their reference.

Schema Triggers
Schemas distort our view of others and interpersonal situations. When our schemas
get triggered, we react in ways designed to protect ourselves from the emotional pain
that results. Triggers are unavoidable. However, if you can identify the triggers for
each of your schemas and consciously notice when those situations arise, you’ll be
one step closer to changing the reactions that typically follow, and therefore one step
closer to minimizing the pain associated with the schema and the problematic coping
behavior that follows. Here are some of the typical triggers for each schema:

Abandonment and instability. This schema is likely to be triggered when you’re

with someone who is unpredictable, unstable, or unavailable. When this schema is
triggered, you’ll experience anger, fear, and grief.

Mistrust and abuse. This schema is likely to be triggered when you believe that
people you’re interacting with will hurt or betray you. When this schema is triggered,
you’ll experience anger, fear, and yearning.

Emotional deprivation. This schema is likely to be triggered if you feel lonely, if

you’re with a detached partner, or if you don’t feel understood, protected, or loved.
When this schema is triggered, you’ll experience sadness, loneliness, and anger.

Defectiveness and shame. This schema is likely to be triggered when you start to
get close to someone and feel that your defects will be exposed, when others
criticize you, or when you’re in a situation that makes you feel that others will find
you inadequate, flawed, or unworthy. When this schema is triggered, you’ll
experience shame, anger, and sadness.

Social isolation and alienation. This schema is likely to be triggered when you’re
in situations or groups of people and feel different or left out. When this schema is
triggered, you’ll experience fear, anxiety, anger, loneliness, and shame.

Dependence and incompetence. This schema is likely to be triggered by any life

changes or new situations or the end of a relationship with someone you rely on
heavily. When this schema is triggered, you’ll experience anxiety, fear, and anger.

Failure. This schema is likely to be triggered when you’re with people who are
more successful than you or when you’re in situations that make you feel that
you’re lacking in terms of accomplishments, talents, competence, or intelligence.
When this schema is triggered, you’ll experience sadness, shame, anger, and fear.

Entitlement. This schema is likely to be triggered when things don’t go your way or
when your needs and desires aren’t put first. When this schema is triggered, you’ll
 experience anger.

Subjugation. This schema is likely to be triggered when you’re in situations and

relationships where the needs of others come first or where you feel controlled by
others. When this schema is triggered, you’ll experience sadness and anger.

Unrelenting standards and hypercriticalness. This schema is likely to be

triggered when you feel that you or others haven’t met your high standards. When
this schema is triggered, you’ll experience anger.

Interpersonal Domains
Events that can trigger schemas occur within six interpersonal domains:
work, friends, family, intimate relationships, parenting, and community.
Bring the focus to these domains to help clients identify and understand
their vulnerability to schemas in a variety of relationships. For each domain,
ask, “With regard to your schema [ideally, you’d mention a specific
schema], what situations seem to trigger it at work?” If clients identify a
particular interpersonal event, keep pushing. Ask if there are additional
experiences, conflicts, or interactions that activate the schema and its
related affect. Keep asking until you’ve identified as many situations and
interpersonal events as possible. Use the Schema Triggers Worksheet to list
these situations. Work through all relevant domains to identify a number of
schema-triggering events that the client struggles with across a wide range
of situations.
Encourage clients to observe schema-triggering events as they occur
and note the related affect as it emerges. However, also explain that the
point is not to control triggers and the accompanying painful emotions;
rather, the point is to learn to recognize when schemas and schema-related
affect are activated in relationships. To help clients develop this awareness,
you can give them the Schema Events Log and ask them to complete it as
homework, recording triggers and emotions any time they notice that a
schema has been activated.
The Schema Events Log is designed to help clients recognize and
observe schema-related events as they occur. The more clients are able to
mindfully watch schema-triggering events, the more likely it is that they’ll
be able to exert control over their responses in the future.
 It’s important to acknowledge and validate the painful emotions
associated with each schema-triggering event. When experiencing painful
emotions, it’s a natural reaction to want to escape the pain. It’s useful to
help clients observe and document each step of the triggering process. The
more clients know about their triggers and the better they can recognize
them as they occur, the greater the chances that they will be able to change
problematic interpersonal behaviors. The following example dialogue
shows how you can do this:
Therapist: (Looks at the client’s Schema Events Log.) I see your coworker
said something that felt very critical.
Client: Yeah, that I don’t seem to give a shit about the job—that I look
disinterested.
Therapist: And that seemed to activate your defectiveness schema?
Client: Yeah. I felt sick, like I was really screwing up. And then I started to
get angry, like who the hell is this person?
Therapist: So it felt like something was wrong with you, and that was…
Client: Like a kick in the stomach. It was this worthless feeling.
Therapist: And then you got angry.
Client: I told her to mind her fucking business and said that I didn’t care
what she thought.
 ACT and Schemas
ACT recognizes that pain is inherent in human existence. From the ACT
point of view, schema-related pain isn’t pathological, nor is it something
that can be overcome. Because schema-related pain has its origins in early
childhood, it is an enduring part of the individual’s experience. No matter
what age we are or how long we have been in therapy, we are unlikely to
fully emancipate ourselves from schemas and schema-related affect. For
example, among people who had early abandonment experiences and
learned to expect them, the abandonment and instability schema is likely to
be triggered during every relevant interpersonal event. The criticism,
withdrawal, and anger of others will activate the schema and the fear that
goes with it.
The focus of ACT for interpersonal problems is not to eliminate
schemas and schema-related pain; rather, it is to learn to respond differently
when schemas are triggered. ACT makes a clear distinction between the
primary pain that is part of the human condition and the secondary pain, or
suffering, that results from the struggle to avoid the unavoidable. From the
ACT point of view, schema affect is primary pain—an unavoidable by-
product of living. Therefore, the target of the treatment protocol in this book
is not to stop or block the primary pain related to schema activation.
Instead, the focus is on easing secondary pain: the suffering generated by
attempts to avoid schema affect.
Schema coping behaviors (SCBs) lie at the root of interpersonal
problems. Whenever people try to avoid or block primary pain due to
schemas, relationships sustain damage. Therefore, the focus of this
treatment is on clients’ schema coping behaviors. SCBs correspond to the
ACT concept of experiential avoidance, which involves maladaptive
strategies to suppress, numb, manage, and control pain. From an ACT point
of view, the problem isn’t schemas or the emotions they generate; the
problem is trying to avoid schema-related pain with a variety of strategies
that damage or destroy relationships.

Summary
As clients begin to observe their schema triggers and reactions in day-to-
day life, they’ll develop a growing awareness of the powerful role schemas
play in interpersonal events. In the next chapter, we’ll focus on schema
coping behaviors, which are a form of experiential avoidance, and how they
damage relationships. Helping clients develop an understanding of this
dynamic is essential to creating motivation for the arduous work ahead:
learning to accept schema-related pain in the service of values-based
interpersonal behavior.
 Chapter 3

Understanding Schema Coping Behaviors

After helping clients understand schemas, their roots in childhood
experiences, and the powerful role they play in everyday life and
relationships, you can begin to explain schema coping behaviors and assess
their costs. Although these behaviors often provide a bit of short-term relief,
they usually damage relationships in the long run. As mentioned,
understanding this can provide clients with powerful motivation to engage
in the challenging work of changing long-term patterns of behavior in
relationships.

Introducing Schema Coping Behaviors

Here’s an example of how you might introduce schema coping behaviors to
clients:
Therapist: Schema coping behaviors are responses aimed at blocking or
controlling schema-related pain. These coping behaviors may
offer temporary relief in the moment, but in the long run they
contribute to the schema, make it feel more true, and actually
increase schema-related emotional pain.
Both environment and temperament can contribute to the formation of
schema coping behaviors. We often learn these coping behaviors
by watching our parents and other family members deal with
pain. Dad may have gotten angry and gone on the attack when he
was hurt. Mom may have collapsed and given up. A sister may
have withdrawn in her bedroom. A brother may have started to
drink.
In addition, sometimes we come up with schema coping behaviors on our
own. When a schema is triggered, over time we learn a way of
responding that feels like it offers at least temporary relief from
 the intense emotional pain. Because it seems to work, we stick
with it, doing the same thing again and again in similar situations.
The trouble with schema coping behaviors is that they tend to hurt other
people, relationships, and, ultimately, the person who’s using
them. When we withdraw, surrender, or go on the attack,
relationships stop feeling good to the people who are important to
us. After a while they may give up on us or harden and withdraw.
So, although schema coping behaviors may offer some temporary
relief, in the long run they make us feel worse about ourselves—
and may cause us to lose people we love.

Common Schema Coping Behaviors

Although schema coping behaviors are highly individualized, they tend to
follow similar patterns. The SCBs most damaging to interpersonal
relationships can be broadly classified into ten types, described in the
handout Ten Common Schema Coping Behaviors (Young, 2012). The first
five schema coping behaviors all involve overcompensation. The easiest
way to understand this type of coping behavior is to think of it as a more
aggressive response to a schema-triggering event. When people engage in
one of these coping responses, they are fighting the schema. This is akin to
the “fight” part of the fight, flight, or freeze reaction. The sixth schema
coping behavior involves surrender. It can best be described as a more
passive response to a schema-triggering event. Think of it as the “freeze”
aspect of the fight, flight, or freeze reaction to the schema-triggering event.
The last four schema coping behaviors involve avoidance. These responses
to schema-triggering events are attempts to avoid the pain associated with
those events. Think of them as the “flight” component of the fight, flight or
freeze response.
You can use the Ten Common Schema Coping Behaviors handout to
describe maladaptive behaviors to clients, then give them the handout for
their reference.

Ten Common Schema Coping Behaviors

Overcompensation
Aggression or hostility: If you use this coping behavior in response to a schema-
triggering event, you’ll find yourself counterattacking by blaming, criticizing,
challenging, or being resistant.

Dominance or excessive self-assertion: If you use this coping behavior in

response to a schema-triggering event, you’ll find yourself trying to control others in
order to accomplish your goals.

Recognition seeking or status seeking: If you use this coping behavior in

response to a schema-triggering event, you’ll find yourself overcompensating by
trying to impress others and get attention through high achievement and status.

Manipulation or exploitation: If you use this coping behavior in response to a

schema-triggering event, you’ll find yourself trying to meet your own needs without
letting others know what you’re doing. This may involve the use of seduction or not
being completely truthful to others.

Passive-aggressiveness or rebellion: If you use this coping behavior in response

to a schema-triggering event, you’ll appear to be compliant but will rebel by
procrastinating, complaining, being tardy, pouting, or performing poorly.

Surrender
Compliance or dependence: If you use this coping behavior in response to a
schema-triggering event, you’ll find yourself relying on others, giving in, being
dependent, behaving passively, avoiding conflict, and trying to please others.

Avoidance
Social withdrawal or excessive autonomy: If you use this coping behavior in
response to a schema-triggering event, you’ll find yourself isolating socially,
disconnecting, and withdrawing from others. You may appear to be excessively
independent and self-reliant, or you may engage in solitary activities, such as
reading, watching TV, computer use, or solitary work.

Compulsive stimulation seeking: If you use this coping behavior in response to a

schema-triggering event, you’ll find yourself seeking excitement or distraction
 through compulsive shopping, sex, gambling, risk taking, or physical activity.

Addictive self-soothing: If you use this coping behavior in response to a schema-

triggering event, you’ll find yourself seeking excitement with drugs, alcohol, food, or
excessive self-stimulation.

Psychological withdrawal: If you use this coping behavior in response to a

schema-triggering event, you’ll find yourself escaping through dissociation, denial,
fantasy, or other internal forms of withdrawal.

Although these categories are helpful, it’s important to keep in mind

that clients may have different coping behaviors for different schemas, or
even different coping behaviors for the same schema. For example, a client
with an emotional deprivation schema may sometimes demand that his or
her needs be met and at other times give in or surrender. It is critical to
work with clients to identify all the coping strategies they use to avoid
schema-related pain.
Once you’ve introduced the concept of schema coping behaviors and
clients have had a chance to review the handout, you can begin a general
discussion about which SCBs they use most often. The following dialogue
provides an example of how to begin exploring the role of SCBs. The client
in this dialogue has a social isolation and alienation schema:
Therapist: When you look over that list—the ways people tend to cope with
the emotional pain from their schemas—is anything familiar?
Client: Withdrawal. Total disconnection. It’s like, “Screw it. What are you
bothering with these people for?”
Therapist: Anything else? What comes up when you see how different from
you other people are, or when they seem caught up in their lives
and pretty much unaware of you?
Client: Anger. I get very critical and disgusted. If I don’t feel included in
something, I can go on the attack.
Therapist: So when you feel excluded—not belonging or not part of things
—you can go either way: withdrawing or being more critical or
perhaps attacking. Do you have any sense of why you’d choose
one or the other of these coping behaviors?
Client: I think I get angry when I try to make my needs known and people
don’t get it—when they don’t seem to have any concern for me.

Linking SCBs to Specific Interpersonal Situations

Next, clients need to link schema coping behaviors to particular relational
triggers. To achieve this, help them examine schema-triggering situations
and the resulting SCBs in each of the six interpersonal domains: work,
friends, family, intimate relationships, parenting, and community.
Completed Schema Events Logs, from chapter 2, provide a list of schema-
triggering situations. Have clients transfer these to the left-hand column of
the Schema Coping Behaviors Worksheet. (A sample filled-out worksheet
follows the blank form.)
At this point in the treatment process, clients may know a good deal
more about schema triggers than when they first filled out the Schema
Events Log, so encourage them to write down as many additional triggering
situations as they can think of. The more comprehensive this list is, the
better prepared clients will be to recognize schema-triggering events when
they occur.
Next, for each schema-triggering situation, have clients identify their
schema coping behavior and describe it in the right-hand column. If they
have any difficulty identifying their coping behaviors, have them review the
Ten Common Schema Coping Behaviors handout. The following brief
visualization may also help:

1. Ask the client to visualize a specific triggering situation.

2. Ask the client to notice the emotion that situation sets off and to
name the schema.

3. Ask the client to notice any action impulses that arise while
visualizing the situation. What does the client want to say or do to
cope with the pain?
 Examining the Costs of SCBs
Once clients have recognized the link between schema triggers and SCBs,
do an in-depth exploration of some of the most salient triggering situations
—those where schema coping behaviors are impacting important
relationships. The goal is for clients to differentiate between the short-term
and long-term effects of these behaviors. Here’s a dialogue that exemplifies
this process, based on the sample worksheet filled out by Beth:
Therapist: There are a couple of triggering situations with your husband:
when he criticizes something you do, and when he seems kind of
clipped, cold, and uncommunicative.
Beth: Yes. I feel vulnerable with him.
Therapist: Because he can trigger that feeling of unworthiness—the
defectiveness schema, the sense that you’re somehow wrong or
bad.
Beth: Right.
Therapist: So let’s look at how you cope. (Examines Beth’s worksheet.)
When he criticizes, you counterattack—you get angry and talk
about all the things he does wrong. But when he’s cold and
withdrawn, you find yourself clinging and demanding attention.
Those are two very different coping responses.
Beth: When he criticizes, I feel hurt…and ashamed. And I can’t stand that,
so I blow up. But his withdrawal is scary. I feel like he’s getting
sick of me. So I try to pull him close.
Therapist: When you use those schema coping behaviors—getting angry or
trying to pull your husband close—does it make you feel better or
worse?
Beth: I guess I feel better at first. When I lash out, I don’t feel as bad about
myself. And when I get clingy and demanding, I feel like I’m
holding on to him, so I’m a little less scared.
Therapist: And then what? Does the schema coping behavior continue to
help you?
Beth: No. He gets annoyed, and then I feel like something has gone wrong
between us.
Therapist: So the coping behavior helps in the short term, but after a
while…
Beth: Yeah. I feel like I’m screwing things up.
Therapist: So the coping behaviors aren’t a long-term solution. They seem
like they might even strengthen that old schema—the sense of
being unworthy.
As in the above dialogue, work with clients to examine their most
powerful triggers and SCBs. The goal is to help clients see that schema
coping behaviors provide short-term relief from schema affect but that over
time they tend to strengthen schemas and actually produce more schema-
related pain. During this exploration, clients may develop a growing
recognition of how SCBs impact their relationships in different domains.
Encourage clients to recognize their most common SCBs and which
interpersonal situations typically trigger particular coping responses. With
this awareness, clients can begin to watch for these triggering situations and
notice how they react. Explain that changing behavior starts with
recognition: seeing SCBs when or soon after they occur.
Examining schema coping behaviors is hard. Listing and discussing
these maladaptive responses can trigger significant shame. It can also
activate various schemas, particularly defectiveness and failure. Be gentle
with this material. Validate how painful it feels when schemas are triggered
and how normal it is to do almost anything to stop or mask that pain. As
you discuss SCBs, try to describe the behavior nonpejoratively. If SCBs
show up in the session directed toward you—for example, attack,
withdrawal, or surrender behaviors—supportively describe what the client
is doing, identify the schema that has been triggered, and validate the pain.
Then have the client add the in-session triggering situation to the Schema
Coping Behaviors Worksheet.
 For homework, encourage clients to keep observing schema triggers
throughout the week and to use the Schema Coping Behaviors Worksheet to
document any SCBs they engaged in.

ACT and SCBs

As you explore the long-term results of schema coping behaviors with
clients, it should become obvious that these behaviors have strained many
relationships—and that, despite damaged and lost relationships, the pain
associated with their schemas continues. This makes it clear to clients that
trying to avoid schema-related pain with SCBs doesn’t ultimately get rid of
the pain. If anything, it can exacerbate the pain over time.
As noted in chapter 2, schema-related pain is inevitably triggered in
relevant interpersonal situations. ACT calls this unavoidable experience
primary, or “clean,” pain. In essence, SCBs are always attempts to avoid
this unavoidable pain. Although each SCB looks different behaviorally, all
share the same purpose—to avoid or temporarily block schema affect. This
leads to what ACT describes as secondary, or “dirty” pain: suffering that
results from avoidance and maladaptive choices. This secondary pain is the
target of treatment, and diminishing such suffering is the goal of ACT.

Summary
This final introductory step of treatment provides clients with a more
complete understanding of how schemas work. As they identify specific
avoidance strategies and the interpersonal situations in which they are
employed, clients begin to see a pattern and become familiar with their
particular coping response repertoire.
As you normalize SCBs and validate their role in the management of
schema-related pain, you can also begin to reveal the role these behaviors
play in schema maintenance and how they damage relationships in the long
term. The next chapter begins to apply ACT principles and processes to this
theme as you examine the specific emotional and relational costs of SCBs.
 Chapter 4

Cultivating Creative Hopelessness and

Developing Mindfulness Skills
Thus far, you’ve helped clients identify their schemas relevant to
interpersonal interactions and the schema coping behaviors they tend to
engage in. This chapter will guide you in helping clients assess the costs of
those SCBs and how they impact relationships in the key domains of work,
friends, family, intimate relationships, parenting, and community life. This
lays the groundwork and provides motivation for the ACT approach known
as creative hopelessness—the territory where new solutions and behaviors
can be discovered.
An important part of this process is exploring workability by assessing
the impact of SCBs on clients’ relationships. Workability immediately
precedes creative hopelessness. When exploring workability, help clients
recognize the outcomes of their schema coping behaviors. Also explore
whether these behaviors help them feel better, whether they improve
relationships, and whether they bring clients closer to their values.
Recognizing the costs of SCBs and that they aren’t workable in the long run
helps clients arrive at creative hopelessness—the point where they realize
that their schema-related pain is unavoidable and that the problem isn’t the
pain but rather attempts to avoid this pain. Workability and creative
hopelessness are both processes that continue to occur and need to be
addressed throughout therapy.
This chapter also covers teaching clients mindfulness skills—one of six
core processes in ACT. These skills aren’t intended as stress-reduction
techniques; rather, they help clients develop more awareness of schema
affect and the urge to engage in SCBs. They also help create space for
clients to make more authentic choices—values-based choices—about how
they wish to respond to schema-related pain and the urge to engage in
SCBs.
 Assessing the Costs of SCBs
You can use either a formal or an informal approach to help clients evaluate
the costs of SCBs in significant relationships. Either way, take a session or
two to explore this topic and assess the costs in a wide range of
relationships in all relevant domains. Appreciate and validate the pain these
SCBs create. Mourn, for a moment, the losses that truly mattered and
acknowledge the weight of these relational difficulties. The motivation to
change is largely driven by such experiences, so the time you devote to this
aspect of the therapy will pay dividends later on.

Formal Assessment of the Costs

For a formal exploration of the costs of SCBs, ask clients to fill out the
Outcomes Worksheet. For each significant SCB, have clients identify
negative outcomes in the six interpersonal domains. Obviously, not all
domains will be negatively affected; those that aren’t relevant may be left
blank. (A sample filled-out worksheet follows the blank form.)
 Because clients using the Outcomes Worksheet often focus on
behavioral consequences—things that happened—you may need to direct
them toward exploring emotional outcomes. Ask whether they experienced
sadness, loss, loneliness, hurt, guilt, shame, or fear in any domain as a result
of SCBs. As mentioned above, this emotional pain can provide motivation
for the difficult work ahead, so take your time reviewing this material.
Informal Assessment of the Costs
An alternative to the Outcomes Worksheet is tracing outcomes for one
or more SCBs on a whiteboard. You probably don’t need to write down all
the domains; just work with the client collaboratively to list as many
problematic outcomes as possible. At some point during the whiteboard
work, express your growing concern about how much pain these SCBs have
caused and the difficulty of the struggles they’ve created in the client’s life.
An even less formal assessment of SCB outcomes can be done by
asking about several key domains and how schema coping behaviors have
impacted relationships in those domains. Encourage the client to tell some
stories about this, then explore a few of the painful outcomes in depth.
Afterward, summarize and validate, as illustrated in the following example:
Therapist: I’m starting to really understand how that coping strategy of
withdrawing and shutting down has affected you. The old
schema-related pain—feeling somehow wrong and defective—
would clobber you. You didn’t know how to protect yourself from
those feelings except by shutting down. It was all you could do,
and for a little while it seemed to insulate you from the pain.
(Validation.)
But while withdrawing seemed to protect you, it was damaging your
relationships. (Assessing the cost of SCBs.) Your wife got lonely
and was kind of dying on the vine. And finally she just drifted
away, which triggered a tremendous amount of loneliness in you.
At work, when you got criticized and had those “something’s
wrong with me” feelings, you often pulled away and moved on to
another job. But that meant starting over somewhere else, and it
kept putting your career back. I hear a lot of regret about that
now.
And then there was your father—a kind of gruff, hard-boiled guy who hurt
you with his opinions. So you pulled away, and then you never
really got a chance to say good-bye when he died. There’s a lot of
sadness about that.
And now, when your girlfriend asks you to change something or complains,
it sets off the same feelings. Then you shut down, and she
 withdraws from you in turn.
As I listen, I can feel how much you’ve lost because of that way of coping
—how much pain it’s brought into your life. It helps with the
feelings of defectiveness, but only very briefly, and then it
damages the relationships that really matter to you.

Creative Hopelessness
Once you have worked with clients to assess the workability of SCBs and
establish the relational costs of these behaviors, it’s time to make a
directional shift in treatment and move into ACT territory: cultivating
creative hopelessness. This is a critical step in ACT. Creative hopelessness
marks the moment when a client—having recognized the price of
experiential avoidance—considers a new relationship and new response to
pain.
Clients begin to recognize that everything they’ve tried in order to
control and minimize schema-related pain hasn’t worked and that, if
anything, the pain is worse. At this point, you pose a question that will
shape the remaining treatment process: “If running from pain and trying to
suppress or avoid it hasn’t worked, could the answer lie in something quite
the opposite? Could it involve not running away? Could the answer lie in
the pain itself? What if letting yourself feel the difficult emotions connected
to your schemas was the answer?”
The core message is that the more we try to avoid schema-related pain,
the more we have that pain. For things to be truly different, clients must, in
a sense, give up. They must lose hope that any of their old control efforts
will work in the long run. They must see that SCBs haven’t worked and will
never work. The false belief that controlling schema-related pain is possible
has simply been an immobilizing trap.
This is painful, but out of creative hopelessness new hope is born—
hope that facing and feeling schema-related pain is possible and even
desirable, in that it might not exact the terrible toll associated with SCBs.
Because clients take significant risks when they finally face their schema-
related pain, take your time (a session or two) with developing the creative
hopelessness theme. Until clients understand and accept the basic ACT
premise that experiential avoidance (in the form of SCBs) is the cause of,
not the solution to, interpersonal problems, they will probably continue
their habitual avoidance strategies. If you’d like to give clients something to
read that explains creative hopelessness, the Creative Hopelessness handout
may be useful.
Because creative hopelessness can be such a challenging idea, you may
find it useful to have several ways to help clients grasp this key concept.
Metaphors can often be quite effective in explaining creative hopelessness.
Here are two that you might present to clients: the quicksand metaphor
(Hayes & Smith, 2005) and the metaphor of digging a hole (Hayes et al.,
1999).
The struggle to suppress schema-related pain, or any
Struggling in quicksand.
painful emotional experience, can be likened to falling into quicksand. The
more you try to escape, using SCBs or any kind of emotion control strategy,
the faster you sink. All of your struggle only gets you more stuck. What if
you were to stop struggling and resisting? What if you relaxed, fell back,
and gently maneuvered yourself through the quicksand instead of fighting
it?
Imagine that you’re trapped in a deep hole. The only tool you
Digging a hole.
have is a shovel (your old schema coping behaviors), and the only solution
you know is to dig. But digging only makes the hole bigger and deeper. So
you dig into the sides of the hole, but the edges collapse and the dirt pours
in on you. You try to dig steps, but this only dislodges more dirt, which also
pours in on you. So what do you do if you’re in a hole and all you have is a
shovel? The first step is to put the shovel down and stop digging (stop using
old SCBs). Only then can you find a more workable solution.

Creative Hopelessness

Feeling stuck and at your wits’ end is an important moment, because it offers a lesson
that can change your life. Knowing in your mind and in your heart—with absolute
certainty—that the things you’ve done to manage schema-related pain don’t work is
the first step on a new road. Admitting and accepting that trying to stop schema-
related pain has only created more suffering for yourself and the people you’re close
 to creates a paradoxical new freedom. Because all of your old ways haven’t worked
and won’t work, you can choose to do something new.

This is a watershed. It starts with acknowledging that your experience is your best
guide. What does your experience with your schemas and schema coping behaviors
tell you? In the long term, do your coping behaviors work or not? Do they help you or
not? Are they good for your relationships or not? Take some time to really consider
those questions.

When you answer these questions, the situation may feel hopeless. Yet there is hope
because there is another way. Hope starts when you give up all of your old efforts to
control schema-related pain. They haven’t worked, and they won’t work in the future.
In fact, the false belief that control is possible, that somehow you can stop the pain,
has kept you trapped in a strategy that doesn’t work.

Your experience tells you that efforts to control pain aren’t working and that things
only seem to get worse. All of your old strategies for coping with schema-related pain
led to a dead end. That’s why you need to try something new. If running from pain and
trying to suppress or avoid it hasn’t worked, could the answer lie in something quite
the opposite—in not running away? Could the answer lie in the pain itself? What if
facing the pain connected to your schemas is the answer?

Stopping the Struggle

How can clients stop the struggle with schema-related pain? From the ACT
point of view, schema-related pain is as unavoidable as bad weather. But
like bad weather, schema-related pain comes and goes. It’s triggered by
negative interpersonal events that cause a surge in schema affect (shame,
fear of loss, hurt, sadness, and so on) and schema-driven cognitions (“I’m a
failure,” “I’m unlovable,” “I’m not good enough,” “I’ll never get what I
need,” and so on). However, every day we have dozens of emotions and, by
some estimates, sixty thousand thoughts. So thoughts and emotions are
temporary events that keep shifting and changing. If clients can learn to
observe and wait, rather than fight and resist, these private events will
evolve and recede, making way for the next thought or emotion.
Another metaphor, one that is both simple and profound, can be very
effective for helping clients see their experience as transitory: the metaphor
of being the sky, not the weather. Harris (2009) notes that this metaphor
appears in Buddhist, Taoist, and Hindu teachings. The sky is always there,
holding the constantly changing weather. The weather is sometimes cloudy
and dark, sometimes snowy, sometimes rainy, and sometimes sunny, with a
gentle breeze and fluffy white clouds. While wind, storms, rain, and
sunshine come and go, the sky remains, receiving each change of weather
with perfect willingness. The sky is the self, holding an endless stream of
ever-changing private events. Here’s an example of how you might present
this metaphor:
Therapist: Having different kinds of weather is necessary in life. After all,
we wouldn’t take the same delight in a beautiful sunny day if
every day was bright and blue. Plus, we need rain and snow to
supply water. Similarly, we need difficult emotions to let us know
when we’re off course or have lost sight of what’s important.
Do you think you could observe all of your weather without struggling with
it or trying to change it? Could you just observe the sensations in
your body, the thoughts in your head, and the emotions that surge
up and recede? Sometimes you’re happy, sometimes sad,
sometimes fearful. Would you be willing to notice all of your
experience as it unfolds, moment to moment?
Difficult thoughts and emotions, like the ones triggered by your schemas,
are like a terrible, scary storm with thunder, lightning, and
howling wind. Eventually the storm quiets and the air clears. The
sky simply holds these storms. Could you be like the sky and stop
struggling with the weather? Could you learn to just watch it as it
comes and goes, just seeing painful thoughts and feelings show
up and then fade away?

Cultivating Mindfulness
You are proposing radical change to clients at this point: watching pain
without struggling with it; being the steady, clear self that allows passing
thoughts and feelings to have their moment; and seeing that no matter how
painful these private events are, they are temporary and are not the self. But
how can clients learn to observe rather than try to control their experience?
Fortunately, humans have known the answer for several thousand years:
mindfulness.
In this section, you’ll find several exercises to help clients cultivate
mindfulness: Mindful Focusing, the Five Senses exercise, and mindful
activities. Once you’ve taught Mindful Focusing, ask clients to practice
daily for several weeks until the skill is well developed, and be sure to
check in weekly to determine how often they’re practicing. We also
recommend starting each session with about three to five minutes of
Mindful Focusing to help underscore the importance of this technique.

Mindful Focusing
The following simple focusing exercise is an easy way to teach
mindfulness in session and also a good practice to assign for homework
between sessions. To begin, have clients observe their breath, all the way
from their nose down to stretching sensations in their diaphragm. Then have
them notice when private events arrive, labeling them simply as “thought,”
“emotion,” or “sensation.” If you wish, you can also make an audio
recording of the guided practice for clients to use at home. Here’s a sample
script for a five-minute practice (adapted from McKay, Davis, & Fanning,
2011):
Therapist: Close your eyes and take a deep breath, noticing the experience
of breathing. Observe perhaps the feeling of coolness as the
breath passes through your nose or throat… Notice the sensation
of your ribs expanding as the air enters your lungs… Be aware of
your diaphragm muscle, which separates the lungs from the
abdomen and is located just below the rib cage. Feel it stretching
with the breath and relaxing as you exhale.
Just keep watching your breath, letting your attention move along the path
of flowing air… In and out…in and out. As you breathe, you will
also notice other experiences. You may be aware of thoughts.
When a thought comes up, whatever it may be, just say to
yourself, “thought.” Simply label it for what it is: “thought.” If
you’re aware of a sensation, whatever it may be, just say,
 “sensation,” to yourself. And if you notice an emotion, just say to
yourself, “emotion.” Simply label it for what it is: “emotion.”
Try not to hold on to any experience. Just label each one and let it go. Then
wait for the next experience. You are simply watching your mind
and body and labeling thoughts, sensations, and emotions. If
something feels painful, just note the pain and remain open to the
next thing that comes up. Keep watching each experience,
whatever it may be, labeling it, letting it pass, and noticing what
comes next.
Let it all happen while you watch: thoughts…sensations…feelings. It’s all
just passing weather, while you are the sky. Just watch…and
label…and let go.
Let the meditation continue in silence for another two minutes, then end
it by asking clients to open their eyes and return their attention to the room.
Encourage clients to do this exercise daily to help them become more
comfortable with and skilled at observing private experiences.

The Five Senses Exercise

Another way to teach observational skills is to guide clients in
sequentially focusing on each of their five senses. Have them attend to each
for about thirty seconds: hearing, smelling, seeing, tasting, and touching.
Although the whole exercise lasts only two and a half minutes, in this brief
time clients are encouraged to observe as many experiences as possible in
each modality.

Mindful Activities
An optional process for increasing clients’ ability to observe their
experience is encouraging them to engage in mindful activities. Each week,
ask clients to add one more mindful activity to their repertoire until they
reach a maximum of four to six. Encourage them to do these mindful
activities daily. Here are some suggested activities:
 Mindful dish washing. Notice all of the sensory experiences of
washing dishes: the warm water, the slippery soap, the hard edges of
dishes and utensils, the sound of running water, the smell of the
soap, and so on.

Mindful walking. Notice how pressure shifts through different

areas of the feet with each step, how balance shifts, and how the
arms swing. It’s fine to count steps, but not necessary. Also notice
the sights, sounds, and smells while walking. This can be done in
the course of normal daily walking; for example, to and from work
or school.

Mindful gardening. Notice the temperature of the soil, the feeling

of resistance while pulling weeds, the thrust of pushing in a trowel,
the scent of flowers and other vegetation, the colors and shapes of
the plants, and so on.

Mindful bathing or showering. Notice the sound and feel of the

water, the slipperiness of the soap, the scents of soap and shampoo,
and the shifting sensations as water sprays on various parts of the
body.

Mindful eating. Notice the color and texture of the food, its
temperature, the aromas and flavors, the sensations of lifting a fork
or spoon, and so on.

Mindful drinking. Notice the feeling of the liquid in the mouth,

including its temperature and viscosity. Also notice its aromas and
flavors, feelings in the throat and stomach, the texture and weight of
the glass or cup, and so on.

When engaging in mindful activities, the goal is to stay with sensory

experience. If thoughts or other private events come up, they should simply
be noted while returning attention to the five senses.

Working with Resistance to Mindfulness Practice

 Because Mindful Focusing operates both as exposure to painful private
events and as training in observational skills, some clients will avoid it.
This is where you have to encourage, cajole, and push clients to practice
this new skill. Here are a few things you can try with clients who have
significant noncompliance:

Make an audio recording of the Mindful Focusing exercise and set a

specific time and place for the client to practice it each day.

Alternate with less challenging mindful processes, like the Five

Senses exercise or a simple mindful activity, such as walking or
eating an apple mindfully.

In session, gradually increase the time devoted to Mindful Focusing

from five minutes to ten minutes or even longer.

Observing Interpersonal Experience

Once clients’ mindfulness skills have improved over three or four sessions,
begin to guide them toward observation of interpersonal experiences. It’s
helpful to begin with a list of schema triggers so clients can be on the
lookout for these events and remember to use their observation skills as
triggers arise. We recommend that you first teach clients to observe schema-
related emotions, thoughts, sensations, and action urges in session, using
imagery from recent upsetting events.

Listing Schema Triggers

Begin by listing interpersonal experiences that the client identifies as
schema triggers. The Interpersonal Triggers Worksheet can facilitate this
process. A sample worksheet filled out by Maria, a forty-three-year-old
elementary school teacher, follows the blank form. Maria, who is divorced
and lives with her thirteen-year-old son, has very active abandonment and
defectiveness schemas.
Maria’s SCBs include aggression or hostility, social withdrawal, and
compliance (in the form of excessive attempts to please her son), but that
isn’t what’s important now. First, she needs to hone her observational skills
so that she can take note of these triggering interpersonal situations as they
occur.
Observing Schema-Triggering Events in Day-to-Day Life
In this step of treatment, help clients make a list of potential
interpersonal events that could activate their schemas over the following
week, including triggering people and specific behaviors or events. For
Maria, this might include her weekly call to her mother, picking up her son
on Sunday from his weekend with her ex-husband, the feedback meeting
with her principal, and her son’s criticizing behavior.
In each of the triggering situations listed, and particularly when clients
notice the first rush of schema affect, the focus should be on observing
inner processes. Encourage clients to watch the following private
experiences:
 Noticing schema-based affect: observing how feelings wax and
wane, and how they sometimes morph into other feelings (for
example, hurt into anger)

Noticing schema-relevant thoughts: observing thoughts come and

go and trying not to become attached to any of them

Noticing physical sensations: observing sensations that accompany

the interpersonal event, like feeling flushed or tense

Noticing impulses: noting the urge to act and somehow avoid the
schema affect—typically urges to engage in SCBs

Noticing that they have a choice: realizing that it isn’t necessary to

act on the urge

This last point is the most important component of the observational

experience. It allows clients to learn that the impulse or urge to act doesn’t
require action. Actual behaviors need not be synonymous with the SCBs
clients feel the urge to engage in. Encourage them to see the moment when
the impulse enters their awareness and, at that moment, to recognize they
have a genuine choice about whether to do what the mind and body urge.
If you wish, you can have clients use the Interpersonal Experiences
Diary to record their observations during schema-triggering events.
Over the next three to five weeks, question clients about interpersonal
events that triggered schema affect. What did they observe? When they
experienced schema-driven urges, did they choose to act or not? If you keep
encouraging them to use mindfulness skills to notice these crucial moments,
they will gradually become more skillful at watching private events. The
key is consistent attention so that clients come to expect that you’ll explore
these themes. If you pay attention to mindfully observing triggering events,
they will too.

Interpersonal Experiences Diary

Event: ___________
 ___________
Schema emotions: ___________
___________
Schema-related thoughts: ___________
___________
Physical sensations: ___________
___________
Schema-driven urges: ___________
___________

Circle one: Acted on urges Didn’t act on urges

Event: ___________
___________
Schema emotions: ___________
___________
Schema-related thoughts: ___________
___________
Physical sensations: ___________
___________
Schema-driven urges: ___________
___________

Circle one: Acted on urges Didn’t act on urges

Event: ___________
___________
Schema emotions: ___________
___________
Schema-related thoughts: ___________
___________
Physical sensations: ___________
 ___________
Schema-driven urges: ___________
___________

Circle one: Acted on urges Didn’t act on urges

Practicing Interpersonal Observation Skills in Session

You can assist clients in learning interpersonal observational skills in
session by using schema-triggering imagery. Have clients recall and
visualize a recent interpersonal event that caused schema affect. Encourage
them to recall visual, auditory, and kinesthetic aspects of the encounter.
Take some time to let the emotion build. When they report significant
affect, encourage them to provide a verbal description of the event,
covering all of the components detailed in the Interpersonal Experiences
Diary: emotions, thoughts, sensations, and urges. Here’s a transcript
showing this process:
Therapist: Try to notice as much as you can about that moment when your
mother criticized your blouse as cut too low. Notice where you
are, what the room looks like… Hear all the sounds: your
mother’s voice, any other sounds in the environment… Notice
how your body feels and whether you’re touching anything. Are
you there? Are you in the experience?
Client: Yes. It’s pissing me off all over again!
Therapist: Even though it’s upsetting, that’s what we want. Now you have a
chance to just watch the experience. Okay, so the feeling is anger?
Can you describe it a little more?
Client: I’m humiliated, really. That’s where it starts. A little girl who’s done
the wrong thing.
Therapist: And the anger shows up as part of that?
Client: Yes. Ashamed and then angry.
Therapist: Okay, just keep observing your experience. Are there thoughts
that go with the feeling?
Client: She’s done it to me again. She got me again. I’ve screwed up.
Therapist: Are there feelings in your body? Notice what’s happening there.
Client: I’m hot—in the face. I’m blushing.
Therapist: And what do these feelings make you want to do? Do they urge
you to some action?
Client: I want to yell at her. I want to just explode—to scream.
Therapist: Okay. Just watch that. Notice that it’s just an urge, and that you
could have a choice about whether to follow through.
Client: Well, I’m not going to yell at her in your office.
Therapist: (Laughs.) Right. You wouldn’t do it here. But just notice the
push inside to do it—the drive. Notice that it’s something you
could act on or not. If you were with your mom, you could choose
to turn that into behavior, or you could choose not to. Or maybe
you could choose to do something completely different.
Client: Yeah. There’s this urge to yell, but maybe…I don’t have to.
Therapist: Right. So this is what I’m encouraging you to observe every time
something happens in one of these triggering situations. Notice
the emotion—or there may be several emotions, like this time.
Also watch any thoughts that come up. Try not to get involved in
them or attached to them. Just notice that the old defectiveness
schema is pushing up some thoughts. Also see if you can observe
any sensations—things happening in your body. And then notice
any action urges. Watch them just like you did here, and notice
that you have a choice, right in that moment—that you could turn
them into action, or you could choose not to.
Client: (Nods.)
Therapist: This week you’ll undoubtedly have several opportunities to
observe your schema feelings, thoughts, and urges. Sometimes
 you may get involved in the moment and forget to observe. But if
you commit to observing your experiences, there’s a good chance
that you’ll be able to notice them sometimes, watching all of this
weather inside of you, along with the urges to engage in SCBs.
And, most of all, notice that you have a choice about whether to
act on them.
Client: I’ll do my best, particularly with my mother and my son. I don’t like
what I’m doing in those relationships.
Therapist: Fair enough. Observe what happens there.
You may want to repeat this exercise several times, particularly for
clients who resist keeping an Interpersonal Experiences Diary or who don’t
notice the moment of choice and continue to slip into old SCBs.

Summary
The focus of this chapter is teaching clients to recognize the presence and
impact of schema coping behaviors (in ACT terms, experiential avoidance).
Identifying the costs of SCBs lays the groundwork for creative
hopelessness. At this stage, clients must confront the reality that, in the long
term, control strategies have failed. Trying to escape pain is merely creating
more pain and deepening it into suffering. The key here is to recognize that
doing more of the same can only yield more of the same. Once clients
recognize this and arrive at creative hopelessness, treatment moves from
learning about the problem to processes for actively changing the situation.
This starts with developing mindfulness skills, with an eventual focus on
observing interpersonal interactions. Helping clients become more aware of
schema-triggering events and the related emotions, thoughts, sensations,
and behavioral urges will begin to open space for them to make authentic,
values-based choices about how to respond to schema-related pain.
 Chapter 5

Clarifying Values and Committing to Values-

Based Action
As clients become more proficient at observing schema affect and action
urges, the focus shifts to making changes in patterns of interpersonal
behavior. At this point, clients should be increasingly noticing the moment
of choice: the point where they can choose between falling back on old
schema coping behaviors and doing something different. Together, you and
the client are now ready to address two critical goals:

Creating a plan for behavior change. The old schema coping

behaviors must stop. But trying not to do something leaves a
behavioral vacuum and often fails. So the ACT approach helps
clients develop specific intentions that reflect their interpersonal
values and then helps them transform those intentions into
committed actions in relationships.

Developing a values-based rationale for facing schema-related

pain. In ACT terminology this is called willingness, and it hinges on
having a reason for facing and accepting schema-related pain: so
that clients can live and engage in relationships in a way that’s based
on core values rather than avoidance (SCBs).

This work begins with clarifying core values in regard to relationships

and then identifying specific behavioral intentions to increase values-based
living. The next step is to begin assessing the degree to which clients are
living in accordance with their values. Through all of this work, contrast
committed action with resorting to old coping behaviors.

Explaining Values
Over the course of a session or two, help clients identify and clarify their
core values in all relevant interpersonal domains (work, friends, family,
intimate relationships, parenting, and community). The goal is to help
clients identify ways of relating that truly matter to them in each of these
areas. This opens the door to differentiating between schema coping
behaviors and ways of relating that are based on values. Here’s a suggestion
for how to introduce values into the therapeutic dialogue:
Therapist: All of these schema coping behaviors we’ve talked about are
having a big impact on your relationships. But it doesn’t have to
be that way. There are probably ways you’d rather be and rather
act—ways based on your values—that could make relationships
feel very different. If it’s okay with you, I’d like to explore what
some of your values regarding relationships might be. Then
maybe we can figure out what you could do differently if you
brought those values into your relationships.
Next, define what values are and aren’t, being sure to distinguish
between values and goals:
Therapist: Your values are a direction you want to go. They help you figure
out who you want to be and how you want to act in each domain
of your life. Here’s an example: If someone says, “I want to be
the kind of friend who is there for people, who listens and helps
and is always on their side,” that’s a value. It sets a course in
relationships in the realm of friendship. A value indicates where a
person wants to go and how the person wants to be.
A value is different from a goal. A goal might be to help a friend fix his car
or give him a ride to the airport. Unlike values, those are specific
actions that you can finish. You can say, “I accomplished that.”
But a value is a way of living that matters to you. In relationships,
it’s a way of being with people. You never “accomplish” a value;
you just keep going in that direction.
I’d like to spend a little time exploring some of your values in relationships.
Would that be okay with you?
When you introduce and define the concept of values, be sure to
indicate that values are personal, not dictated by social norms, other
people’s expectations, or even what clients think they should value. In ACT,
the definition of values includes the phrase “freely chosen” to reflect this
key quality of authentic values.

Clarifying Interpersonal Values and Intentions

Now it’s time to get specific. Explore the six domains of interpersonal
relationships and, for each that is salient to the client’s life, work
collaboratively to identify at least one interpersonal value. In this chapter,
we’ll use examples involving a client named Rebecca, a thirty-five-year-old
woman who struggles with failure and mistrust schemas. The dialogue
might begin like this:
Therapist: Rebecca, when you think about your work relationships, are
there some guiding principles for how you’d like to be and act
with work colleagues, or even your supervisors?
Rebecca: I don’t know.
Therapist: Okay. I’m wondering what sort of person you want to be with
colleagues or bosses. Maybe it’s different for each; I don’t know.
But think about how, if you acted on your values, you would be in
those relationships.
Rebecca: I guess I’d want to give honest feedback about what we’re doing
but not be mean or critical, like I can be. Just say what needs to be
done, in a supportive way.
Therapist: Okay. You want to tell a supportive version of the truth about
what’s going on with tasks and projects. Anything else?
Rebecca: I think I’d like to support my coworkers’ initiatives and creative
ideas—not be full of judgments and criticisms.
You can do this process in session and record the client’s responses on
the Valued Intentions Worksheet. An alternative is to assign the worksheet
as homework and discuss the values the client identifies in the next session.
When using the worksheet, whether as homework or to structure a
discussion, have clients assign a rating of importance to each domain using
a scale of 0 to 2, where 0 means not important, 1 means moderately
important, and 2 means very important. For any domain rated above 0,
clients should identify one or two key values in regard to relationships in
that domain. Values can often be stated as general principles and usually
indicate a way of being; for example, being honest, being open, or being
supportive.
The next step is to convert these general values into specific behavioral
intentions. For example, how, exactly, would a client turn the parenting
value “giving my children the experience of being loved” into action?
Specific intentions might include “spending time each evening finding out
what their day was like” or “using validation rather than anger while setting
limits.” Generating specific intentions allows clients to develop a targeted
plan for behavioral change based on their values.
 Contrasting Values-Based Behaviors with SCBs
As you help clients map their values, it’s useful to draw a contrast between
schema coping behaviors and behavior based on interpersonal values. Start
by identifying an SCB that shows up in a specific domain. Then ask clients
to explore differences between the SCB and how they would act in that
relationship and situation based on their values. Here’s an example dialogue
with Rebecca:
Therapist: I know that old failure schema gets triggered by your boyfriend.
When you feel you’re not doing it right, not living up to what he
expects, you get drawn into schema coping behaviors—usually
withdrawal or being critical. How do your values about this
relationship contrast with those old coping behaviors?
Rebecca: I want to validate and appreciate him rather than criticize him.
Therapist: What about the old failure feelings?
Rebecca: I know. That’s why I criticize. I try to make it seem like he’s got a
problem, not me.
Therapist: So how is your new intention going to change that?
Rebecca: I want to focus on what’s really great about him and tell him that,
not all the critical stuff.

Cultivating Willingness to Accept Schema Affect

The good news is that values-based intentions regarding relationships can
often replace problematic SCBs. But the bad news is that clients must be
willing to accept painful schema affect. Acting on values rather than
running away from schema-related pain means clients must look at and face
that pain. They have to be with feelings of defectiveness, deprivation,
failure, or whatever schema-related affect shows up. And at this point,
clients haven’t learned all of the ACT processes that will help them face
this pain. Still, you do need to clearly acknowledge that this is the task.
Here’s a dialogue outlining how you might do so:
Therapist: When you stop criticizing and instead say out loud the things you
appreciate about your boyfriend, what’s going to happen with the
old failure feeling?
Rebecca: I don’t know—it will probably be worse.
Therapist: Why?
Rebecca: Because when I’m not focused on his screwups, I’ll fall back into
my crap.
Therapist: Could I ask you this: Would you be willing to feel that when it
comes up—the old failure pain—so you could act on your values
in this relationship? Could you experience those painful feelings
so that you can validate and appreciate your boyfriend?
Rebecca: That’s what I want to do. But that failure stuff is like a screaming
banshee.
Therapist: I know. It’s a hard choice.
Rebecca: (Nods.) I do want to change this.

Assessing Values-Based Living

Once you’ve identified clients’ interpersonal values, you can begin
measuring how effectively they stay on course week by week. The simplest
way to do this is to review actions in each domain using a values compass.
A values compass is made by drawing a circle and putting a dot in the
middle of it. Where north would appear at the top of a compass, write a V,
for values. Have clients rate how much or little their behavior over the past
week reflected their values in each domain by drawing an arrow from the
dot in the middle of the compass to a point on the circle. The closer the
arrow points to the V, the more their behavior matched their values in this
domain. Conversely, the farther from the V—at worst pointing straight
down—the less their behavior was aligned with their key values.
An alternative to the compass is to simply rate each week’s adherence to
values in each domain on a scale of 0 to 10, where 0 indicates no values-
based behavior and 10 means that essentially all behavior in that domain
was values-based.
An easy way to set up either assessment is using multiple copies of the
list of six domains. As you discuss clients’ efforts to align their
interpersonal behavior with their values over the previous week, you can
use the scale of 0 to 10 to indicate the degree of values-based behavior.
Alternatively, you can draw a circle for a values compass next to each
domain and have clients draw in an arrow to indicate degree of compliance.
Either way, the assessment can lead to a discussion about barriers to values-
based action in certain domains.

Using Commitment to Overcome Barriers

Encourage clients to regard their intentions as commitments—commitments
to themselves to do what matters, to be who they want to be in
relationships. A commitment to one’s values is no less sacred than a
promise to a loved one. In essence, it means saying, “I will do this because
it’s important, because old schema coping behaviors are damaging my
relationships, and because there’s another way to live.”
Emphasize how effective formal commitments can be in motivating and
assuring behavioral change. Also emphasize that commitments—
particularly commitments to values-based behavior—often run into barriers.
Validate how hard this is.
It’s worthwhile to review these commitments during most sessions.
Have any of the intentions changed? Did specific barriers to values-based
behavior arise? Are clients willing to renew their commitment to key
intentions out loud with the therapist? Remind clients that making a
commitment in this way, formally and in public, increases its power and the
likelihood of following through.
Here’s an example dialogue where the therapist helps Rebecca review
and renew her commitment to values-based behavior in her relationship
with her boyfriend:
Therapist: Rebecca, this turned out to be a hard week with your boyfriend.
He complained about your work schedule, and that set off
feelings of failure. And then you slipped into criticizing to try to
protect yourself from that pain. I understand.
Rebecca: I was on him for all this little stuff.
Therapist: And the arrow you put on the values compass is pretty close to
straight down.
Rebecca: Yeah. I kind of lost my way last week.
Therapist: Okay, that was last week. The failure feeling really got to you.
But this is a new week, a fresh start. And even though some of
that old pain might show up, do you want to recommit to your
intention to validate and appreciate rather than criticize?
Rebecca: Yes, that’s what I want.
Rebecca is struggling with significant barriers to her commitment.
There are emotional barriers, such as her sense of failure and incompetence
in the relationship. At one point, Rebecca said, “I feel like a relationship
idiot.” There are also cognitive barriers: negative self-labeling and thoughts
about past relational failures. In addition, there are behavioral barriers.
Rebecca wonders whether she even knows how to show appreciation or
give praise. In her words, “It sounds stupid and contrived when I say stuff
like that.”
This is a critical point in treatment. Clients have to acknowledge and
face these barriers while also maintaining a commitment to their values and
intentions in relationships.

Labeling Barriers
The first step in dealing with barriers is to label what they are. The mere
act of describing the obstacles to values-based behavior can make them
seem less overwhelming. To do this, use the Assessing Barriers Worksheet
to help clients identify specific emotional and cognitive barriers that are
likely to show up for each values-based intention. Take your time with this
important step, devoting at least one session to exploring barriers.
The emotional barriers to values-based action in relationships are
usually schema affect: fear of rejection, abandonment, hurt, or failure, plus
shame, emotional hunger, and anger. These have usually already been
named as you explored schema-related pain and its impacts on
relationships. The cognitive barriers are schema-relevant thoughts that
predict rejection, abandonment, hurt, or failure. They also show up as
cognitions about past losses, failures, and so on and negative judgments
about oneself and others. These thoughts serve to intensify both schema
affect and SCBs.
 Behavioral barriers, which aren’t on the worksheet and are beyond the
scope of this book, include skill deficits (for example, lacking key
interpersonal skills) and logistical problems, such as physical distance,
financial costs, or time constraints.

Facing Barriers
As clients move toward values-based interpersonal behavior, emotional
and cognitive barriers are likely to emerge. An excellent way to recognize
and work with them is through the monsters on the bus metaphor (Hayes &
Smith, 2005). Hold this metaphor in reserve for exploring a value or
intention of great importance to clients, then devote about half a session to
developing the metaphor. It provides a powerful explication of the key ACT
concept that avoiding uncontrollable schema-related pain results in
dysfunctional and damaged relationships, whereas willingly facing and
accepting the pain opens the door to creating functional relationships based
on core interpersonal values.
To begin, ask clients to focus on one important relational value. Then
suggest that living and directing one’s life is analogous to driving a bus. As
clients steer the bus (their life) toward a key value, certain monsters
(barriers) show up to block the way. There are emotional monsters (schema
affect) and cognitive monsters (schema-driven thoughts). Here’s a sample
dialogue with Rebecca that shows how to engage clients in this metaphor:
Therapist: Okay, Rebecca. Let’s imagine that you’re driving your bus,
which means steering your life, toward your value of being honest
and supportive with your coworkers. That value is up ahead, and
you’re driving toward it. What specifically will you do as you
turn that value into action?
Rebecca: I’m going to state my concerns about the new software, but I’m
going to do it gently, not harshly. My usual mode is to go on the
attack—kind of snipe and exaggerate problems so I can look
super-competent. And when people have good, creative ideas, I’m
going to support them, even if it makes me look less smart or like
I’m not doing that great of a job. Often I kind of snipe at people’s
ideas.
Therapist: Because their good ideas set off that failure feeling.
Rebecca: Yes.
Therapist: So you’re driving your bus toward these values, and I guess we
can already see one of the monsters that jumps up in front of you.
That failure feeling—the fear that you’re not as smart or not
doing as good a job.
Rebecca: Right. It’s a big, ugly one.
Therapist: Are there other emotional monsters?
Rebecca: Yeah. The feeling that I can’t trust these people—that they’ll
climb up on top of me to get ahead. I’m afraid they’ll make me
look stupid or like I’m not contributing.
Therapist: So you have a feeling of distrust, fearing that colleagues might
hurt you. Anything else?
Rebecca: A fear that I’m going to lose my job.
Therapist: What about those mental monsters—the scary or painful
thoughts?
Rebecca: Like I just said, the thought that they’ll lay me off. I also have this
judgment about myself—that I’m not that smart or capable and
that I’ll be exposed.
Therapist: Anything else? Imagine that you’re acting on your value at work:
being supportive and gentle, not harsh.
Rebecca: Here’s a monster: the thought that some of them don’t like me and
are waiting to screw me.
Therapist: Okay, so the emotion monsters and the mental monsters are all
jumping up and down in front of your bus. They’re trying to stop
you. What happens if they make you stop or force you to steer in
another direction?
Rebecca: I go back to my old crap.
Therapist: The old schema coping behaviors: sniping, criticizing, and
attacking.
Rebecca: (Nods.)
Therapist: What happens then?
Rebecca: I screw up my relationships at work. I get isolated and angry. This
has happened at other jobs.
Therapist: Okay. That doesn’t work. You’ve gone that direction with your
bus before and bad things happened. But the monsters are still
jumping up and down, blocking your way. What are you going to
do?
At this point, let clients struggle to figure this out. After you’ve given
clients some time with this conundrum—that experiential avoidance and
SCBs don’t work but the barriers are formidable—reveal the solution: The
answer is to let the monsters on the bus and keep driving in a valued
direction.
Therapist: What if you opened the bus door?
Rebecca: And let them on?
Therapist: Right. Let all the monsters take seats behind you on the bus—all
of them jumping up and down and screaming, “You’ll be a
failure,” “You’ll be fired,” “People don’t like you,” “They’ll hurt
you,” and on and on. What if you just take them with you, along
with all of their caterwauling, while you drive in the direction of
your values?
Rebecca: It’s hard even just listening to that.
Therapist: Right, but if you take them with you, you can go where you want
to go. You’re free to move and be the person you want to be.
This metaphor can be a touchstone throughout treatment. It highlights
the key choice in ACT: avoidance versus facing and feeling the pain while
living one’s values. The barriers (monsters) will always show up, but clients
don’t have to let those obstacles control their behavior.
 Here’s a recap of the steps for developing the monsters on the bus
metaphor:

1. Introduce the basic metaphor, in which navigating through life and

moving in the direction of values is imagined as driving a bus.

2. Focus on specific values-based behaviors (intentions) in a particular

domain. Have clients take some time to describe and visualize this
behavior.

3. Encourage clients to identify emotional and cognitive barriers

(monsters) that may come up as they engage in the new behavior.

4. Explore the outcome of avoidance and SCBs: steering the bus away
from the monsters—and away from their values.

5. Explore how clients can move toward their values with the
monsters.
 Awareness with Willingness
It’s important to continue to encourage clients to mindfully observe
interpersonal events. In the earlier work, clients began to observe
interpersonal interactions that triggered their schemas and used the
Interpersonal Experiences Diary to record their schema-related emotions,
thoughts, physical sensations, and behavioral urges.
 Now these same observational skills are applied to situations where
clients are acting on their values. Because values-based interpersonal
behavior frequently entails facing barriers (schema affect and cognitions),
this is exactly the time to encourage mindful awareness. In addition to
watching their cognitive and emotional barriers to valued living, clients can
also observe their willingness to face this pain. You can use the Awareness
and Willingness handout to guide clients in mindfully observing their
experience. You can also give them the handout and even assign this
practice as homework.

Awareness and Willingness

Whenever you choose to act on your values, watch what happens:

Observe and mentally label emotional barriers that make you want to avoid taking
valued action; for example, fear, shame, sadness, or anger.

Observe mental barriers; for example, thoughts of danger or attacks on or

judgments about yourself or others.

Observe impulses to act. What urges to engage in old coping behaviors do you
experience?

As much as possible, hold on to a willingness to experience whatever thoughts and

feelings arise while acting on your values.

If you want, you can write these observations down, or you can simply keep them in
mind for the next session.

In the Interpersonal Experiences Diary in chapter 4, each entry ended

with the question of whether clients acted on urges to engage in SCBs. In
addition, they were encouraged to make the choice of whether to do so
mindfully. Now there’s a new question: Can clients be willing to face and
experience these monsters—to bring them on the bus so they can continue
moving in the direction of their values in relationships? Notice that we’re
using the word “willing” again. That’s because this is essentially an
exposure exercise. Clients are asked to experience and observe schema-
related pain, however it shows up and for as long as it lasts. They’re
encouraged to stay with it, to be willing to have these painful cognitive and
emotional experiences without running away. Why? So that they can act
based on their values in relationships, even though that often brings pain.
Here’s another example dialogue with Rebecca that focuses on this issue:
Therapist: So this week’s intention with your boyfriend is to validate
something you appreciate about him each day—and to do this
instead of complaining, which sometimes protects you a little
from the failure feelings. Would you also observe what happens
when you praise him and afterward use your mindfulness skills to
see what feelings and thoughts come up?
Rebecca: I’ll do my best.
Therapist: Remember willingness? Would you be willing to let the monsters
on the bus—let them chatter and say all of their painful stuff, and
still act on that commitment to be supportive with your
boyfriend?
Rebecca: (Long pause.) I’ll let the failure stuff on the bus. But I don’t know
how long I can keep it there. Okay?
Therapist: Just keep watching and see what happens.
Awareness with willingness returns to two themes that run throughout
treatment:

Mindful awareness allows clients to observe their experience and

make conscious choices.

In the face of painful affective and cognitive barriers, clients can

choose to engage in either avoidance or willingness. Willingness to
be with whatever there is to experience creates the foundation for
values-based behavior.

You should touch on these themes in most of the remaining sessions.

Also, note that mindful awareness of experience is a form of exposure.
Throughout treatment, facilitating exposure to emotional and cognitive
barriers, while also encouraging willingness, will anchor the therapy
process.

Summary
This phase of the work focuses on identifying core relational values,
identifying specific behavioral intentions, and measuring clients’ adherence
to values—and, throughout this process, contrasting clients’ values-based
intentions with old coping behaviors. Once valued intentions are identified,
the focus shifts to helping clients distinguish between values-based
behaviors and old ways of coping, while also continuing to help them see
the costs of avoidance and the benefits of willingness, even in the face of
challenging barriers. This is the key to commitment and therefore the key to
overcoming barriers. The monsters on the bus metaphor can be a powerful
way of reinforcing this concept, setting the stage for developing awareness
with willingness. This returns the focus to themes that have great relevance
to the remainder of the treatment: observing one’s experience and making
conscious choices, and choosing values-based behavior in spite of barriers
and schema-related pain.
 Chapter 6

Defusing from Thoughts and Developing the

Observer-Self Perspective
The work in the previous chapter firmly established the ACT formulation
that efforts to avoid uncontrollable pain (including schema-related cognitive
barriers) only result in secondary pain, or suffering. This provides crucial
motivation for clients to abandon avoidance in favor of their values. As they
do so, however, schema-driven thoughts tend to show up in a big way, so
now the focus shifts to cognitive barriers. Here are some typical examples:

This won’t work. I can’t do this.

Others will see how screwed up I am.

I’ll be rejected or left.

Others will hurt me.

I can’t do anything right.

If I’m honest, others will be disgusted.

Schema-driven thoughts tend to fall into three categories: predictions of

rejection, hurt, or failure; memories of past losses or failures; and negative
judgments about oneself or others. The cumulative effect of these
cognitions is pressure to return to old, familiar schema-driven behaviors:
attack, surrender, or avoidance. If clients are to make real changes in how
they relate, they need new resources to deal with these painful and
discouraging thoughts.

Building Awareness of Thoughts

In order to respond differently to schema-driven cognitions, clients must
first notice them and begin to understand how they work. Explain that
thoughts occur spontaneously and that we have little control over their
frequency or content—that they’re going to show up whether we like it or
not. Schema-driven thoughts are likely to arise whenever clients attempt to
engage in new, values-based behavior—and in response to any schema-
relevant interpersonal event. For example, if a client who struggles with an
abandonment and instability schema experiences the slightest hint of
rejection, thoughts predicting loss and abandonment will almost certainly
come up.
Explaining this concept shouldn’t take long. You can accomplish it in a
few minutes using a couple of helpful metaphors: the popcorn machine
metaphor and the tug-of-war metaphor (Hayes et al., 1999).
Suggest that the mind is a popcorn machine that
The popcorn machine metaphor.
keeps popping up thoughts eternally. Nothing can turn it off. Pop after pop,
kernel after kernel, the mind continues generating thoughts. Emphasize that
blocking or stopping these thoughts isn’t an option. The mind is a machine
that keeps creating whatever thoughts it likes, whenever it likes.
Suggest that trying to resist or argue with schema-
The tug-of-war metaphor.
driven thoughts is like getting into a tug-of-war with your mind. The more
you struggle and try to get rid of or refute a thought, the harder the mind
pulls on the other end of the rope. It can always cook up more judgments,
predictions, and negative memories. The only way out is to drop the rope
and stop trying to control the mind. Encourage clients to let thoughts come
and go, even those that are painful and disturbing. Every effort at control is
just picking up the rope and returning to that tug-of-war.

Not Buying Into Thoughts

When painful thoughts occur, clients need to know that, once again, they do
have a choice about how to respond. They can attempt to suppress the
thought, they can buy into the thought, or they can simply notice it and let it
go. The first two strategies simply aren’t workable. As the tug-of-war
metaphor indicates, and as research has proven (Wegner, 1989), attempting
to suppress or block thoughts doesn’t work. And buying into thoughts—
taking them seriously and accepting them as true—can lead to cognitive
chaining, where one negative thought begets another in long, thematically
related sequences.
You might take up to half a session to cover this material, perhaps using
the metaphor of a sales representative to explain why it isn’t a good idea to
buy into thoughts (Vuille, 2006a):
Therapist: Picture your thoughts as sales representatives. If you don’t
express interest, some of them go away quietly; they aren’t very
insistent. But then there are the pushy salespeople. They’ll hang
around and keep popping up, trying to entice you with a suitcase
full of products. If you say okay and give them your attention,
before long the suitcase is open and stuff is spread out all over
your living room. If you go for one product, suddenly the
salesperson has a bunch of other things to sell you.
Some thoughts, like the hardcore sales rep, are very compelling, and they
keep coming back to bother you. But as soon as you take them
seriously and give them a lot of attention, or buy into them, you’ll
get bombarded with another related thought, and then another,
and then another.
Remember the monsters on the bus and the thought monsters you
encountered? Which of the thought monsters connected to your
schemas are really good sales reps? Which of those thoughts do
you tend to buy into? Go ahead and list a few of them for me
now.
This metaphor is getting at two key concepts: First, some thoughts are
more compelling than others. It’s relatively easy to let go of thoughts that
aren’t relevant to painful schemas. But it’s tempting to buy into charged,
schema-related thoughts, opening the door to the chaining effect. Second,
buying into thoughts is a choice. It doesn’t have to be an automatic response
when a compelling thought shows up, but it’s much more likely when
clients give thoughts significant attention and serious consideration.
So if suppressing thoughts and buying into them only makes them
stronger and more disturbing, what else can clients do? They can choose the
third option: simply noticing thoughts and then letting them go. This more
effective response to schema-driven thoughts is the ACT process known as
cognitive defusion.

Cognitive Defusion
Cognitive defusion has its roots in the Buddhist practice of observing and
distancing from thoughts (Hayes et al., 1999). ACT offers a wide array of
defusion techniques, all with the effect of changing one’s relationship to the
mind. Observing thoughts and then labeling and releasing them facilitates
detachment, or defusion. As a result, the thoughts are given less attention
and are taken less seriously. As clients learn defusion, they find that instead
of being a thought (for example, “I’m selfish” or “I’m unlovable”), they can
simply have the thought (“I’m having a thought that I’m selfish” or “I’m
having a thought that I’m unlovable”). Being a thought makes a thought
seem absolutely true. Clients gets fused to it and stuck with it. Having a
thought promotes the understanding that it’s just a thought, one of tens of
thousands each day.
Cognitive defusion has four component skills: watching thoughts,
labeling thoughts, letting go of thoughts, and distancing from thoughts. In
this chapter, we’ll offer a variety of exercises and thought experiments (all
adapted from McKay et al., 2011, and some based on Hayes et al., 1999) to
help clients develop each component skill.
Fusion with thoughts tends to be very deeply ingrained, arising as a
result of our earliest learning about language and communication. Therefore
defusion can be a challenge. Take two to three sessions to guide clients
through all four components of defusion sequentially. The first week assign
homework of a daily watching exercise, the second week assign homework
of a daily labeling and letting go exercise, and the third week have clients
experiment with various distancing techniques daily.
One final note before we get into specific defusion techniques: In
practice, ACT therapists frequently work on schema-driven thoughts and
emotions at the same time, merging defusion with emotion exposure.
However, we’ll cover exposure to emotions in the next chapter, presenting
the two techniques sequentially for greater clarity. This isn’t meant to imply
that these approaches should be implemented sequentially in therapy.
Watching Thoughts
The starting point of defusion is learning how to watch the mind. There
are several effective methods for teaching this. In this protocol, we use
Mindful Focusing (see chapter 5) and the White Room Meditation. As you
introduce defusion, we recommend that you start with the White Room
Meditation.

THE WHITE ROOM MEDITATION

The White Room Meditation is an eyes-closed practice in which clients
imagine their mind as a white room through which their thoughts pass. You
can either describe key elements of the practice or read the following script:
Therapist: Imagine that you’re in a white room, completely empty of
furniture or any adornments. You can position yourself anywhere
in the room: at the ceiling, on the floor, in one of the corners—
wherever you like. But wherever you put yourself, visualize an
open doorway on your left and a second open doorway to your
right. The doors open onto darkness; you can’t see anything
beyond.
Now imagine that your thoughts are entering from the doorway on your left,
passing across your field of vision, and exiting through the
doorway on your right. As your thoughts cross the room, you can
attach them to a visual image—a bird flying, an animal running, a
hulking mafioso, a balloon, a cloud, or anything else. Or you can
simply say the word “thought” to yourself. Don’t analyze or
explore your thoughts. Allow each to have a brief moment in your
awareness and then exit through the doorway to your right.
Some thoughts may feel urgent or compelling. Some may want to stick
around longer than others. Just let each one move on out the door
to make room for the next thought. As new thoughts show up,
make sure you’ve relinquished the old ones, but don’t worry if
they show up again. Lots of thoughts tend to repeat themselves,
and the visitors to your white room may be no exception.
After the meditation, discuss with clients whether their pace of thinking
changed, how easy or difficult it was to let go of thoughts, and the relative
urgency of various thoughts.

MINDFUL FOCUSING
Once clients have explored the first process for watching thoughts (the
White Room Meditation), revisit Mindful Focusing, from chapter 5. Guide
clients in Mindful Focusing for four to five minutes, encouraging them not
to pay a lot of attention to the thoughts. Ask them to simply label each one
(“There’s a thought”) and then observe their breath until a new thought
shows up. For at least two weeks, give clients a homework assignment of
doing five minutes of Mindful Focusing each day. As they get more
experience observing cognitive processes, discuss whether they are
experiencing any changes in their relationship to thoughts. Is there any shift
in terms of intensity, believability, or intrusiveness?

Labeling Thoughts
Building on observing thoughts, the defusion skill of labeling thoughts
emphasizes that cognitions are products of the mind (Hayes et al., 1999).
They aren’t real or a priori truths. They are just thoughts.
In ACT, a key approach to thought labeling is to teach clients the phrase
“I’m having the thought that ___________ .” Here are some examples:
“I’m having the thought that Linda will leave me.” “I’m having the thought
that I can’t be honest.” “I’m having the thought Bill is distant because he
sees how screwed up I am.”
Alternatively, clients can use the phrase “Now my mind is having a
___________ thought.” Labels you could recommend for this exercise
might include “fear” thought, “judgment” thought, “should” thought, “I’m
bad” thought, “why” thought (explaining why something happened), and so
on. Work collaboratively with clients to develop labels that reflect their use
of language and their schema beliefs.
Next, have clients observe a sequence of thoughts, labeling each as it
comes up: “Now my mind is having an ‘I’m bad’ thought… Now my mind
is having a ‘she’s bad’ thought… Now my mind is having a ‘fear’
thought… Now my mind is having another ‘fear’ thought… Now my mind
is having a ‘why’ thought,” and so on.
 Whenever clients express schema-driven thoughts, help them label the
cognition as often as possible. Here’s an example dialogue:
Client: I realize when my girlfriend tells me how I don’t talk about my
feelings that she’s trying to make me feel bad about myself—
trying to make me feel wrong.
Therapist: Is that thought familiar?
Client: Yes.
Therapist: Does it connect to any of the schemas we’ve talked about?
Client: (Long pause.) Defectiveness, I guess. That’s how it makes me feel,
anyway.
Therapist: What happens if you just label the thought: “I’m having the
thought that…”? Could you try that?
Client: I’m having the thought that she wants to make me feel bad.
Therapist: What do you notice when you label it?
Client: It sounds weird, like it’s a little ridiculous.
Therapist: Yeah, like it’s just a thought…not quite as serious. Remember
those other labels we came up with, like “judgment” thought and
“fear” thought? What sort of thought is this?
Client: I guess it’s a “why” thought. I’m trying to figure out why she tells
me that.
Therapist: What do you notice now about the thought?
Client: It feels farther away, not as big a deal.
Next, the therapist confronts the problem of getting the client to use this
process on his own:
Therapist: How could you remember to do this when you’re not in here—
for example, when something comes up between you and your
girlfriend?
Client: (Long pause.) I guess when I’m upset…
Therapist: That could be a cue. What could you do when you’re upset?
Client: I could see what my mind is doing—notice my thoughts.
Therapist: Okay, and what could you do then?
Client: Just say, “My mind is having a ‘such and such’ thought.”

Letting Go of Thoughts
Once clients have practiced observing and labeling thoughts, you can
teach them a variety of techniques to help release thoughts and let them go.
Recommend that they experiment with several of the following exercises to
see which are most effective for them.
Encourage clients to imagine each thought as an autumn
Leaves on a stream.
leaf falling from a tree and landing on the surface of a swiftly moving
stream. As each leaf hits the water, it gets swept into the current and
disappears around a bend downstream. With each new thought, clients
should visualize the same set of images.
Billboards.Have clients imagine driving down a long stretch of highway. As
each thought shows up, it appears on a billboard ahead. Encourage clients
to briefly note the thought and then imagine their car sweeping past.
Have clients visualize a clown holding the strings to a dozen
Balloons or clouds.
helium balloons. As each new thought arrives, a balloon detaches and floats
away on the wind. Alternatively, have clients visualize a blue sky with
occasional clouds passing overhead. They can put each thought on a cloud
and let it drift away.
Computer pop-ups. Have clients imagine each thought as a pop-up
advertisement or reminder on a computer screen. They can briefly take note
of each thought and then let it disappear until the next pop-up appears.
Have clients imagine a railroad crossing with a slow freight
Trains or boats.
train grinding past. Each new thought is yet another boxcar rolling by.
Alternatively, have them visualize fishing boats passing beneath a bridge
one by one, with each boat carrying a single thought out of sight.
Whereas all of the previous letting-go exercises are based
Physically letting go.
solely in imagery, this one is somewhat physical. We encourage you to
practice this exercise together with clients. Have clients hold out their right
hand, palm up, as you do the same. As each thought arrives, imagine briefly
holding it in your hand. Then rotate your hand so your palm is facing down
and imagine the thought dropping down and out of sight. Then return your
hand to the palm-up position to receive the next thought. Keep dropping
thoughts each time they show up. Making the letting-go process physical
helps it feel more powerful and real.

Combining Watching, Labeling, and Letting Go

Once clients understand the first three components of defusion—
watching, labeling, and letting go—they can put them together in a single
process. The easiest way to accomplish this is to have clients choose one
labeling technique and combine it with one of the letting-go visualizations
or the physical letting-go technique. We recommend that you have the client
choose and then practice together. This allows you to both model the
behavior and encourage a bit of risk taking as both of you reveal the
frequency, if not the content, of thoughts. Here’s a sample dialogue:
Therapist: Okay, let’s see if we can put labeling and letting go together.
Which labeling strategy do you want to use?
Client: I like “I’m having the thought that…”
Therapist: Fine. And letting go—do you want to use a visualization or drop
the thought from your hand?
Client: Drop it from the hand.
Therapist: Okay, let’s do it together. As soon as either of us has a thought,
we’ll say to ourselves, “I’m having the thought that…” And then
we’ll turn our hands to drop it. (Therapist and client randomly
turn their hands as they drop thoughts.)
 If the client chooses a visual letting-go strategy, there won’t be any
outward indication of a passing thought. In this case, keep a running tally,
out loud, as you each let go of thoughts. Continue the exercise until one of
you reaches about twenty thoughts.
Some clients prefer physically letting go by turning their hand but are
embarrassed about doing so in public. To deal with this, suggest more
subtle movements, such as a slight spreading of the fingers, a gentle lifting
of the fingers as if waving good-bye, and so on.
Encourage clients to practice labeling and letting go daily at specific
times. When the time comes, it doesn’t matter whether their thoughts are
troubling. It’s important that they master this defusion technique, and
rehearsing at times when they aren’t distressed will help them remember to
use defusion when difficult, schema-driven thoughts show up. Also practice
the technique in session as salient situations arise:
Therapist: Can you just label that thought and let it go?
Client: Right now?
Therapist: Yes.
Client: My mind is having a “fear” thought. (Pauses.) Okay, I put it on a
leaf.
Therapist: Now what do you notice?
Client: I’ve sort of moved on from it.
Therapist: If it comes up again, could you say so and do the same thing—
just label and let it go?

Distancing from Thoughts

Certain defusion exercises are especially effective for creating space
between the self and the thought. Practicing these techniques helps clients
learn to take cognitions less seriously. Distancing processes have a common
element: They embrace a painful thought while, paradoxically, allowing it
to diminish in importance. Here are several distancing exercises. Encourage
clients to experiment with all of them to see which techniques are most
effective for them.

THANK YOU, MIND

Explain to clients that the mind is always trying to help them survive.
It’s constantly working to protect them from danger, make judgments about
what’s good or bad for them, or explain why things happen. But sometimes
the mind goes overboard, finding danger when there isn’t any, making
painful negative judgments, or explaining things in such a way that clients
feel ashamed or wrong. One way to respond to these thoughts is to thank
the mind for its efforts. As each painful, schema-driven thought shows up,
encourage clients to use the mantra “Thank you, Mind, for that thought,”
and then let it go.
This exercise can be done as a long sequence of thank-yous: “Thank
you, Mind, for that ‘fear’ thought… Thank you, Mind, for that ‘I’m bad’
thought… Thank you, Mind, for that ‘judgment’ thought,” and so on.

NEGATIVE LABEL REPETITION

Negative label repetition is also called Titchener’s repetition (Titchener,
1916), based on Edward Titchener’s discovery that repeating any word fifty
or more times begins to rob it of all meaning. Even highly disturbing words
or phrases spawned from schema-driven thoughts lose most of their punch
with repetition. When clients present a self-judging thought that they find
disturbing, encourage them to use negative label repetition. Before starting,
try to reduce the thought to something pithy, like “bad husband,” “selfish,”
or “hurtful and mean.” Have clients repeat the word or phrase out loud
quickly, while still pronouncing it clearly, for at least one minute.
Then help them explore what happened to the meaning of the word or
phrase. In most cases, clients report that the word or phrase began to feel
odd or empty—more a sound than a word. If this technique works for
clients, encourage them to use it at home when they notice schema-driven
self-judgments.

OBJECTIFYING THOUGHTS
One way to shrink the power of painful thoughts is by objectifying
them, imagining them as physical objects (Hayes et al., 1999). To use this
technique, ask clients to imagine the thought as an object, then tell you its
color, size, shape, texture, and so on. It’s easier for clients to distance
themselves from thoughts that have been assigned physical properties.

CARD CARRYING
In this defusion technique, clients carry index cards on which they write
down schema-driven thoughts as they come up. Then, whenever these
painful cognitions recur, clients can remind themselves, “It’s on the card,”
and let it go.

WEARING LABELS
Painful self-judgments that show up repeatedly can be defused by
actually wearing them. Do this exercise together with clients so you can
model the process and share some of the embarrassment. Each of you
should write a recurring self-judgment on a sticky note or name tag and
wear it for the remainder of the session. Toward the end of the hour, share
with each other how the impact of the negative label has changed. Although
the judgment was probably disturbing at first, the words may have lost
much of their power by the time you remove the labels.

THE FOUR KEY QUESTIONS

Once a client has gained some understanding of defusion and is starting
to use it with schema-driven thoughts, you’ll both begin to recognize which
thoughts are the most frequent and powerful. For these recurring cognitions,
especially any that block values-based behavior, ask the client four key
questions:

1. How old is this thought? How long has the client been thinking
this? Five years? Ten? Since childhood?

2. What is the function of this thought? What is the mind trying to

achieve? Most schema-driven thoughts, at root, are designed to help
people avoid some kind of pain. A slightly different way to get at
the function of a thought is to ask the client what this thought is
trying to protect him or her from feeling.
 3. How is the thought working? Is the thought effective at protecting
the client? Or does the client still struggle with the very feelings this
thought was supposed to help him or her avoid?

4. Would you be willing to have this thought and still act on your
values in relationships? Even though this difficult thought shows
up and tries to drive the client back to old coping behaviors, would
he or she be willing to have the thought while taking action on
valued intentions?

These questions usually help clients gain distance from schema-driven

thoughts as they realize that these thoughts don’t work and haven’t worked
for a long time. The fourth question embodies one of the two key points
interwoven throughout this therapy: that clients can choose to be the person
they want to be in relationships, understanding that in most cases this
requires a willingness to have painful, old thoughts—to take these thoughts
with them as in the monsters on the bus metaphor.
Here’s an example dialogue with Rachel, a forty-six-year-old woman
with defectiveness and emotional deprivation schemas, illustrating how the
four key questions can facilitate the distancing process:
Rachel: I tried not to shut down and go cold. I really did. But every time my
brother repeats all of his horror stories about growing up with
Mom, I… I want to appreciate his struggle, to really listen. But I
turn to ice.
Therapist: What thoughts come up when you try to listen to him?
Rachel: He’s an asshole. All he really cares about is himself. I took just as
much shit from her, but he doesn’t even know about it, much less
care.
Therapist: What’s the schema?
Rachel: No one cares. (Blending defectiveness and deprivation.)
Therapist: And you’re thinking that?
Rachel: Yeah. I don’t matter. To him or my mother. I’m a nothing—just
someone to complain to.
Therapist: That thought really gets to you. How old is it, do you imagine?
Rachel: How long have I had it? Since I was a kid.
Therapist: What do you imagine the purpose of that thought might be?
What’s your mind trying to do?
Rachel: It’s trying to keep me from being hurt, I guess—trying to stop me
from caring about them.
Therapist: Is that working? Do you feel less hurt and vulnerable?
Rachel: No. I get hurt all the time.
Therapist: So what’s the outcome of those “nobody cares” thoughts? What
happens after you buy into them?
Rachel: I’m angry and hurt. I’m tremendously upset that they don’t give a
shit. It kills me that nobody cares what I go through.
Therapist: Does anything else come out of those “nobody cares” thoughts?
Rachel: Like I said, I get cold. I withdraw. And then my brother complains
about that! He gets upset and says I’m not listening.
Therapist: So, if anything, those thoughts make you feel more hurt, rather
than less hurt. And they also pull you away from your value of
listening and understanding. Are they working at all? Are they
doing anything positive for you?
Rachel: (Shakes head.) No.
Therapist: Those thought monsters are likely to show up any time you’re
intending to really listen to and connect with your brother. The
schema gets activated, and then the thoughts come up, right? I’d
like to ask you something: Would you be willing to have those
thoughts and still listen to your brother? Would you be willing to
stay focused so you can really understand him?
Rachel: (After a silence.) Just assume I’m going to have the thoughts
because I always do? And then keep listening, regardless?
(Sighs.)
Therapist: It’s a hard thing, isn’t it?
Rachel: It is, but I can work on that.
Notice how the distancing questions about the age, function, and
workability of thoughts prepare clients to experience schema-driven
cognitions as less useful and believable. They also make it possible to ask
for a key commitment: being willing to experience painful thoughts while
choosing to act in alignment with interpersonal values. In this example,
Rachel won’t be able to hear and understand her brother until she accepts
and gains some distance from those “nobody cares” thoughts.

Practicing Defusion Skills

As you can see, there are many techniques for helping clients defuse from
thoughts. All can be effective. Sometimes the challenge is simply
remembering the techniques and deciding which will be effective in
different circumstances. To help with this, give clients the Defusion Skills
handout, which lists all of the skills covered in this chapter. (Appendix C
includes an alternative handout, which lists fewer skills and provides brief
descriptions of the skills listed. You can use whichever version you prefer.)
Once you’ve taught clients all of the techniques and have given them
the handout, use the following exercise to give them some practice in
choosing and using defusion skills. Start by having clients identify four to
six schema-driven thoughts that have created barriers to values-based
interpersonal behavior. Then briefly review the defusion skills they’ve been
learning, using the Defusion Skills handout to provide a reminder.
Next, start giving voice to clients’ schema-driven thoughts, throwing
them at clients randomly. Clients can then use any defusion skill that seems
appropriate in response. Here’s an example of this exercise with a client
named Bill, who has a subjugation schema.
Therapist: You’re being so cruel and selfish to tell your girlfriend about
things that bother you in the relationship.
Bill: Thank you, Mind, for that thought.
Therapist: You’re being very inconsiderate of others’ feelings.
Bill: My mind is having a “judgment” thought.
Therapist: She’s going to get sick of you.
Bill: I’m having the thought that she’s going to get sick of me. It’s just a
thought.
Therapist: You have to realize how selfish you’re being. If you don’t think
about this, nobody will want to be around you.
Bill: I hear that thought, and now I’m going to let it go. (Spreads his fingers
as if dropping something.)
Therapist: She’s probably already mad at you.
Bill: I’ll let that one go, too. It’s drifting away, a silly red balloon.
Therapist: You’re too demanding.
Bill: That’s a very old thought—my mother used to say it. All it’s doing is
trying to shut me up.
Therapist: You’re just going around hurting people, and then you’ll be
alone.
Bill: Thanks, Mind, for the “judgment” and “fear” thoughts.
We suggest that you do this exercise with clients several times as
they’re learning defusion skills. Continue to practice defusion in session
through the rest of treatment whenever clients experience schema-driven
thoughts in session. Carefully listen for fused thoughts. Ignoring and failing
to defuse these thoughts in session is perilous because clients will go home
and do the same. You’ll also lose opportunities for clients to practice key
defusion skills under your supervision. In addition, you’ll be modeling
inattention to cognitive processes.
If clients report fusion with schema-driven thoughts between sessions,
ask which defusion strategy they might have used with this thought, then
practice it in session. Encourage them to consider other defusion techniques
as well, and rehearse those in session too.
 Changing Perspective
When clients are fused with thoughts or emotions, their identity is merged
with those private experiences. If they think, “I’m afraid” (versus “I’m
having the thought that I’m afraid,” the self and the fear are essentially
indistinguishable. One goal of ACT is to help clients detach the self from
emotions and cognitions. This is a shift from self-as-content to self-as-
context, or the observer self. Once clients have made significant progress
with defusion, self-as-context work can be introduced over a session or two.
Explain the observer self to clients using the concepts outlined in the
handout The Observer Self. Because this concept can be a little challenging,
you can also give clients the handout to review later.
As is often the case in ACT, metaphors can help clients grasp the
concept of self-as-context—and may even help them directly experience
this perspective. Two metaphors that we find helpful here are the movie
screen metaphor and the chessboard metaphor. You can also use a brief
experiential exercise to help develop the observer perspective. All three
approaches are outlined below.

Movie Screen Metaphor

Suggest to clients that the observer self is a movie screen. Every day a
new movie plays on the screen—tragedies, comedies, adventures, love
stories. All of them are full of emotions, like loss, hope, joy, and fear. And
all have an unending stream of ever-changing dialogue, analogous to the
thoughts the mind constantly churns out. Though the movies, the emotions,
and the dialogue constantly change, the screen is always there and remains
the same.
Encourage clients to detach from current emotions and thoughts and
simply notice all of the experiences that have shown up on the movie screen
today and in the moment. Suggest to clients that they can be the screen,
allowing experiences to come and go and allowing thoughts to come and
go.

The Chessboard Metaphor

With the chessboard metaphor, clients come to see themselves as the
chessboard itself, rather than any of the pieces or the outcome of the game
(Hayes et al., 1999). We recommend keeping a chessboard in your office to
fully utilize this excellent metaphor.

The Observer Self

Sometimes your self—the essential you—gets merged with thoughts and feelings. For
example, you might have the judgment “I’m bad” as if that were you, as if your
essential self were bad. That’s fused thinking—the thought and the self seem like the
 same thing. This contrasts with defusion, where you say, “My mind is having the
thought that I’m bad.” You and the thought are not the same.

You can also get merged with feelings. Saying or thinking, “I’m afraid,” makes it seem
like you are the fear, as if your core self is characterized by fear. That’s different from
noticing in a given moment that you feel afraid—which is a passing emotion and
doesn’t define you. When you have a feeling of fear, you’re observing something that
will change and pass—something that isn’t you. When you are afraid, you are the
fear.

Thoughts and feelings constantly change. They come and go, and throughout all of
these changes you are the one who is watching. This perspective is sometimes called
the observer self. See if you can be aware of this observer self, this self behind your
eyes who watches what you think, what you feel, and what you do and is separate
from all of that. As you observe your self-judgments, you see that you aren’t the same
as those judgments. You aren’t your thoughts, feelings, or sensations. You are the
one who observes, notices, and holds all of these experiences.

Many parts of you have changed over the years: you’ve gotten older, you’ve learned
things, and you see some things differently than you used to. Throughout all of this,
you’ve experienced a continuous stream of ever-changing thoughts and feelings. And
throughout all of this, your observer self has always been there, never changing. See
if you can sense this deeper you.

Start by having the client list at least ten positive and ten negative labels
about himself or herself. Then sit across the chessboard from the client and
initiate a dialogue using the labels. Begin by putting down a chess piece and
stating one of the negative labels out loud, then have the client put down a
chess piece and state one of the positive labels out loud. Continue until all
of the labels have been stated.
This sets the context for exploring the metaphor as follows:
Therapist: Some of these pieces are good, and some are very painful. We
humans struggle to get rid of all these painful thoughts and
feelings that show up when our schemas are activated. There are
moments when you feel insecure, and moments when you feel
very confident; moments when you feel competent, and moments
when you feel like a failure. There are moments when you feel
 awkward, and moments when you feel real and genuine. But what
if you weren’t these chess pieces? What if you weren’t either the
good pieces or the bad pieces? Is there anything you could be
besides these chess pieces? (This isn’t a rhetorical question; elicit
a response from the client.)
If you were a player, you could try to move these pieces around in an effort
to win, but that doesn’t change anything; the player is still caught
in the game and invested in whether the good or bad thoughts and
feelings win. The games just go on and on. Sometimes the good
pieces win, sometimes the bad. Can you think of anything else
you might be other than the pieces or the player? (Again, elicit a
response.)
Here’s an idea: What if you were the board? That way you could have the
pieces but not be the pieces. The board is in contact with the
pieces. It’s aware of the pieces and experiences the pieces. But the
board itself never changes, whether there are more black or white
pieces and no matter where they move. The board stays the same.
It doesn’t care about the game or who wins or loses. So from this
space, the space of being the board, can you see how you can hold
all of your experiences, observing them and yet not being them?

An Experiential Exercise in Being the Observer Self

One effective way to help clients take the perspective of the observer
self is to guide them in watching and describing their experience. Simply
have them identify and label thoughts, emotions, and physical sensations
out loud; for example, “I’m having the thought that ___________… I’m
having a ___________ feeling… I’m having a ___________ sensation in
my ___________ ,” and so forth.
As with defusion, it’s important to continue to encourage clients to
develop the observer-self perspective throughout the remainder of
treatment. You can use this exercise to do so, or simply ask, “Can you just
watch that thought or feeling—just observe your experience as it comes and
goes—without being the experience? Can you be the observer and not the
thought or feeling?”
 Summary
The focus of this phase of treatment is on cognitive defusion and
developing the self-as-context perspective. Defusion has four components
that are best developed sequentially: watching thoughts, labeling, letting go,
and distancing. It’s important to devote sufficient time and practice to this
important work, and it’s essential to note all fused thoughts that occur in
session and help clients defuse from them.
Learning to watch experience as the observer self is made easier by all
of your work with defusion. And, in fact, it is closely related to defusion
skills. Being the observer self is a stance you encourage throughout
treatment, one you can facilitate with simple questions such as “If you were
the sky, what would your weather be right now?” or “What’s playing on
your movie screen right now?”
 Chapter 7

Conducting Exposure with Defusion

As mentioned in chapter 6, ACT therapists frequently work on affect and
cognitions at the same time, merging defusion with emotion exposure.
Although we’re presenting emotion exposure separately, we encourage you
to integrate work on schema-driven affect with work on schema-driven
thoughts.
As with defusing from schema-driven cognitions, clients need to learn
to face schema affect so emotional barriers won’t block them from acting
on values in their relationships. This requires developing acceptance and
willingness. Emotion exposure, in which clients learn to observe and
describe schema affect, is the path to acceptance of difficult emotions. It
promotes willingness to experience whatever emotional pain is necessary as
clients act on their interpersonal values.

Emotion Exposure
When clients experience schema affect in session, fully bring the emotion
into the room. This is done by exploring, in sequence, physical sensations,
the emotion itself, related thoughts, urges to avoid the experience, and urges
to react with typical coping behaviors. This sets the stage for asking clients
whether they’d be willing to have their difficult emotions in the service of
acting on their values-based intentions.
We recommend starting with physical sensations because it’s often
easier for clients to describe a feeling in the body than to explore emotions.
You can conduct in-session exposure either via dialogue with clients or
through guided visualization.

Exposure via Dialogue

To conduct exposure via dialogue, follow the sequence of steps outlined
below:
1. Start with physical sensations. Ask clients what they are feeling
physically. You might use the objectifying approach from chapter 6
here, asking them to imagine what physical attributes the sensation
would have if it were a physical object; for example, “If the
sensation had a color, what color would it be? What shape or size
would it be?”

2. Focus on the actual emotion. Ask clients what emotion goes with
the physical sensations they’ve just described. Then ask them to
describe the emotion. Again, it may be helpful to use the
objectifying approach, asking them to assign physical
characteristics, such as size, shape, color, and texture, to the
emotion. Encourage them to keep finding new ways to describe the
emotion.

3. Ask clients to notice and label thoughts. After exploring the

emotion, ask clients to notice and label any related thoughts. Guide
them in defusing from these thoughts using the techniques in
chapter 6. For example, encourage them to use such phrases as “I’m
having the thought that ” or “Now my mind is having a thought,” or
to simply say, “There’s a thought.” (Letting-go imagery typically
isn’t used during exposure because it distracts from the main task:
experiencing the emotion. Deal with thoughts quickly—just briefly
labeling them—then get back to the emotion.)

4. Ask clients to notice any impulse to suppress the emotion. If they

observe any avoidance, encourage them to resist it and instead focus
on the emotion, trying to be as open to the feeling as possible.

5. Help clients notice any action urges. Ask clients whether they
notice any urges to engage in old coping behaviors, such as
withdrawing, getting aggressive, or saying something dismissive. If
this is happening, suggest that they can simply have those urges
while still focusing on their feelings.

6. Keep circling back to emotions and sensations. Here are some

questions you might ask:
 “What are you feeling right now? Try to describe
everything you notice.”

“Has anything about the emotion changed? Does it

feel more or less intense? Has it transformed into a
different emotion?”

“What are you noticing physically?”

“Have your physical sensations changed in any way?

Describe how they’re different.”

7. Ask about willingness. After clients have observed and explored

the feeling in detail, ask this key question: “Would you be willing to
have this feeling and still follow through on your commitment to
your values-based intention?” (Ideally, you’d state a specific
intention here.) If the answer is no or the client isn’t sure, you
probably need to do additional emotion exposure.

The following dialogue illustrates this emotion exposure process. In this

example, the client is a twenty-one-year-old man struggling with
subjugation and mistrust schemas. Upon noticing the client’s schema-driven
emotional pain, the therapist brings the client’s attention to the emotion:
Therapist: When you had lunch with your father this week, you knew the
topic would come up about your dropping out of the engineering
program. Your intention was…
Client: I know… I meant to tell him in a gentle way what I really want. It
didn’t happen.
Therapist: What got in the way?
Client: The fear that he’d tell me I screwed up—that he’d be angry and
maybe walk out. So I was curt and refused to talk about it.
Therapist: What are you noticing right now as you remember that?
Client: The fear that he would be disgusted with me.
 Once the emotion is acknowledged, you can move through the process
outlined above. Here’s an example, continuing the previous dialogue, to
illustrate how this might play out:
Therapist: What are you noticing right now in your body? Are you
experiencing any physical sensations?
Client: I feel hot in my chest. I have a tight feeling there.
Therapist: Does that sensation feel big or small?
Client: Pretty big. It fills my chest.
Therapist: If it had a color, what would it be?
Client: Black—ugly black.
Therapist: Can you identify the emotion connected to that feeling?
Client: I’m afraid.
Therapist: How could you describe the fear right now?
Client: It’s like he’s going to kill me emotionally—just kick me and kick me
until I’m broken.
Therapist: How big is the feeling?
Client: Huge! The size of a truck… It doesn’t fit inside of me. It’s too big.
Therapist: And the color?
Client: The same—black.
Therapist: If thoughts come up, just label them, saying to yourself, “There’s
a thought.” Then get back to the feeling. What are you noticing
now about the emotion?
Client: I’m just scared that he’s going to reject me. I feel alone, like there’s
no one. He’s going to crush me if I don’t do what he wants.
Therapist: Okay, just thank your mind for that thought. What do you
observe about the feeling now?
Client: I’m still scared, but I’m noticing that there’s also a little anger.
Therapist: See if there’s a part of you trying to get away from the feeling—
trying to distract or distance yourself from it.
Client: Yeah, I’m thinking about applying to school next fall.
Therapist: Just notice that and then see if you can really open yourself to the
fear that your dad is going to reject you. Stay with that. Do you
still have the heat and tightness in your chest?
Client: The tightness is there, but the heat not so much.
Therapist: What do you notice now?
Client: It’s just there. I’m afraid of him. I remember him hitting me when I
was a kid, his big hands.
Therapist: Just notice that thought and let it go. Does the fear make you
want to do something?
Client: It makes me want to be very cold, very walled off.
Therapist: What’s happening with the fear?
Client: It’s kind of sitting there, in my chest. And I’m looking at it, like it’s
some wild animal in the zoo.
Therapist: I want to ask you something that might be important. Would you
be willing to have this fear and still gently and directly tell your
dad what you want?
Client: You mean be honest, not cold?
Therapist: Yes.
Client: (Long pause.) Okay. I’m seeing him Thursday. I’ll talk to him then.
Notice that in this example the fear doesn’t go away or change much.
What’s important is that the client stays with it, that he observes and learns
about the experience. This is a way of practicing willingness: the
willingness to feel pain in the service of his values. Following the in-session
exposure, he’s able to make a commitment that wasn’t possible before: to
take the fear with him and assert his needs with his father. Also notice that
the emotion is the center of the work. The therapist acknowledges thoughts
and avoidance impulses but keeps returning to the affect and sensations.
This is how you keep the exposure going: by repeatedly asking, “What are
you noticing about the emotion now?”

The Special Case of Anger

Anger is a tricky emotion to do exposure with because it can show up
both as schema affect and as a schema coping behavior. Anger is often a
component of schema affect, particularly with emotional deprivation and
entitlement schemas. Exposure work is necessary for clients to develop
willingness to carry the anger while acting on their values-based intentions
in relationships.
On the other hand, with defectiveness, failure, abandonment, and
unrelenting standards schemas, angry feelings and aggressive behavior tend
to fall into the category of schema coping behaviors, covering other, more
painful emotions. In the case of defectiveness and failure, anger often helps
people avoid the primary pain of shame. With abandonment and unrelenting
standards, anger can form an emotional bulwark against fear.
If anger or aggression is functioning as a schema coping behavior, you
must look beneath to uncover the hidden, avoided affect. The focus of
exposure should be the underlying emotions.

Exposure via Guided Visualization

As mentioned, you can also conduct emotion exposure via guided
visualization, and that approach is described below. As you’ll see, the
visualization uses steps similar to those outlined previously, starting with
physical sensations before moving to emotions. The client in this example
is struggling with an abandonment and instability schema that was triggered
when her boyfriend had a busy period at work and wasn’t available for
several days. When they finally spoke, instead of following her intention of
exploring his feelings about the relationship, she exploded. The anger was
functioning as a schema coping behavior, to help her avoid the fear of
abandonment, so exposure to the fear was the ultimate goal:
Therapist: Close your eyes and visualize your boyfriend. Look back for a
moment at that argument… Let yourself be aware of your anger
and what you’re saying… Notice your physical reactions, paying
close attention to your body’s sensations. Notice any difficult,
uncomfortable sensations, perhaps in your stomach, chest, head,
or shoulders. If you note an uncomfortable sensation, just stay
with it. See if you can stop wrestling with that sensation and just
observe it. The point isn’t to like the feeling, but to experience it
as what it is: a sensation in part of your body. Keep observing it
and see if you can feel exactly where that sensation is located,
where it begins and ends… You might even imagine that it has a
shape or color. See if you can let go of any struggle or sense of
defense against this sensation.
As you observe physical sensations, notice whether any thoughts,
judgments, or evaluations come up… If they do, just notice them
and label them, then let them go. Say to yourself, “There’s a
judgment” or “Thank you, Mind, for that thought.” Then let it go
without getting involved with it. Just keep noticing your thoughts
and letting go of each as it arises.
Now notice any impulses. How do you feel pulled to react as you visualize
the argument? Are you feeling pulled to escape? Do you want to
attack? Notice the urges to engage in old schema coping
behaviors.
As you’re observing all of the sensations, thoughts, and impulses that your
anger brings up, notice how the pain is connected to your schema
and see if you notice any other emotion underneath the anger.
Perhaps you were feeling afraid when you became angry. See if
there is fear there now… Are there any other emotions, such as
shame or sadness?
Just observe any feeling that is below your anger. Stay with the feeling and
watch it. See how big it is. See its shape. Notice if it might have a
color.
If you find yourself wanting to escape these feelings, gently bring your
attention back to them. These are the feelings that your anger was
 covering.
Continue in this way for another few minutes, having clients watch and
explore the feelings beneath their anger. Then, before asking clients
whether they would be willing to feel the underlying emotions while acting
on their values-based intentions, have them visualize doing so:
Therapist: Now bring back the image of your boyfriend and see him clearly.
Imagine that this is the moment when you intend to gently ask
him about his feelings about the relationship. Let yourself be
aware of your feelings: the anger, if it’s there, along with the
feelings beneath your anger, the emotions that are so painful to
experience. Now imagine gently asking your boyfriend about his
feelings. Notice your schema emotions as you ask, and simply let
them be whatever they are. Are you willing to have them while
you explore his feelings?
Encourage clients to continue with this aspect of the visualization for a
few moments, simultaneously holding the schema-related affect and an
image of their new, intended behavior.

Exposure and Defusion Combined

Several techniques and exercises merge exposure and defusion into a single
process. At root, these exercises are all aimed at acceptance of schema-
driven thoughts and feelings, which leads to greater willingness to act on
interpersonal values.

Exploring the Flip Side

In the exercise Exploring the Flip Side, exposure consists of listing and
considering schema-driven thoughts and feelings and the costs of old
schema coping behaviors. The physical properties of the written list are
used to help facilitate defusion. Then related values are written on the
opposite side of the paper, creating the context for an experiential exercise
revealing that values-based behavior and schema-related pain are
inseparable. This sets the stage for exploring willingness. Here are the
specific steps:
 1. On a large index card or sheet of paper, list clients’ frequently
triggered schema-driven thoughts and feelings.

2. Label all of these thoughts and feelings “Schema-Related Pain,”

then encourage clients to observe the thoughts and feelings.

3. Help clients defuse from the thoughts by having them count the
number of words in each thought, then the number of letters. Have
clients notice the color of the ink and ask them to read the thoughts
backward.

4. Ask clients, “What have these thoughts and feelings cost you? What
specific things do they keep you from doing?”

5. Explore how these thoughts and feelings have acted as barriers to

values-based behavior and write the underlying value(s) on the flip
side.

6. While clients are in contact with their schema-related pain, ask them
what they want to do with the list of thoughts and feelings. Do they
want to push it further away, tear it up, or throw it away?

7. Have clients notice that pushing the list of thoughts and feelings
away or throwing it away also moves away the value(s) written on
the flip side.

Here’s a sample dialogue illustrating this process. In this example, the

client is a fifty-two-year-old woman struggling with an unrelenting
standards schema:
Therapist: That sadness keeps showing up, doesn’t it? Those high, high
standards keep getting triggered. And when you don’t live up to
them…
Client: I start feeling down and get angry at myself.
Therapist: (Folds a sheet of paper.) Let’s write that schema-related pain
down. There’s the sadness. And there’s anger at yourself. Can you
 get in touch with your anger? It happened just a few days ago
with your business partner.
Client: Yeah, I can feel it.
Therapist: And how about thoughts—what thoughts go with the anger?
Client: Thoughts like “I’m doing it wrong” and “This isn’t good enough.”
Therapist: (Writes everything down.) What are you noticing in your body?
Client: I feel heavy.
Therapist: Still sad?
Client: Yeah.
Therapist: Okay, just be with that. Let’s look at the two thoughts you
mentioned. (Shows the list to the client.) How many words in
each of them?
Client: Um…four…and four.
Therapist: Okay, let’s count the letters in that first thought.
Client: Are you kidding? Okay…fourteen.
Therapist: And how many letters in the second one?
Client: Eighteen.
Therapist: What color is the ink?
Client: Green.
Therapist: Can you read the first thought backward?
Client: Wrong it doing I’m.
Therapist: Okay, can you have these fourteen green letters and observe
them? Can you have them just as they are, just letters and lines on
the paper? What’s that like after a while?
Client: They kind of lose their meaning.
Therapist: What’s happening with your sadness and anger?
Client: They are still there.
Therapist: That’s fine. This schema-related pain—the sadness and anger,
and the thoughts (tapping the paper)—what has this pain kept
you from doing in your relationships?
Client: It’s kept me from keeping my word—from doing what I said I was
going to do even if it isn’t perfect.
Therapist: Right. Let’s write that down on the other side. (Turns the paper
over and writes the value on the opposite side, then turns the
paper back to the side with the schema-related emotions and
thoughts.) What could you do with this paper, with these feelings
and thoughts, if you wanted to get rid of them? Could you put it
across the room—maybe even throw it away? (Moves the paper
far from the client.) You can put the sadness, anger, and thoughts
farther away from you, but if you do, notice what else is farther
away. What else is on the paper?
Client: My value.
Therapist: Right. The farther away your sadness, anger, and difficult
thoughts are, the farther you are from your values. I’m wondering
if you could take this piece of paper with you and keep it with
you for the rest of the week. Would you be willing to have the
feelings and thoughts on this piece of paper if it means that you’ll
also be closer to your value of keeping your word even if you
have to do things imperfectly?

Exposing the “Worst Self”

Exposing the “Worst Self” is a guided visualization in which exposure
consists of having clients vividly recollect a time when schema coping
strategies led to regrettable behavior. To begin, have clients think of a time
when they behaved as their “worst self” with others. Then, to facilitate
defusion, help them notice that they have an observer self that watches the
“worst self” and sees everything it does. Help them take the self-as-context
perspective and observe the feelings, thoughts, and behaviors of their
“worst self.” As they observe this “worst self,” help them notice the
distinction between the core, unchanging self and the schema-driven
thoughts, feelings, and behaviors. This distinction reveals to clients that
they are not synonymous with their worst self. Rather, they are the self that
watches and has always watched every thought and feeling, both good and
bad. Here’s an example script for this visualization (based on Ciarrochi &
Bailey, 2008):
Therapist: You’ve told me about times when schema thoughts and feelings
were so strong that you acted in ways you regret. You might say
you behaved as your “worst self” with others. Think back to a
time when you were at your worst… Imagine, as vividly as you
can, being this “worst self”… Notice the feelings that push and
pull at you. Notice how your “worst self” thinks. Let yourself be
aware of specific thoughts… See how your “worst self” behaves
with others and how far this is from your values.
Now notice that, within you, there’s somebody looking at this “worst self.”
This is a self that watches your “worst self” and witnesses
everything it experiences. This part of you is the observer self.
Even though your thoughts, feelings, urges, and sensations are continuously
changing, there is still a consistent you throughout. There is a you
that can watch all of your experiences without being those
experiences or struggling with them. Just become aware of this
person behind your eyes that watches your “worst self.” Can you
experience what it feels like to be the observer?
Now consider this: If you can observe your “worst self,” then you are not
the same as that “worst self.” If you can observe the thoughts and
feelings connected to your worst self, then you aren’t equivalent
to those thoughts and feelings. You are the observer. Remember
the chessboard? You aren’t the pieces on either side, fighting all
those battles. You aren’t your thoughts, feelings, and sensations.
You are the one who observes, notices, and holds all of these
pieces.
Can you imagine that you are not your breathing and your body and its
sensations, that you are not your emotions or your thoughts?
Many parts of you have changed over the years. Your age has
changed. Your appearance has changed. Your thoughts and
feelings are constantly changing. But the observer self has always
been there, never changing. See if you can sense this deeper
“you.” Think of yourself as being like the sky, being an
unchanging perspective from which you notice and hold the ever-
changing weather of your awareness. See if you can let go of your
attachment to and struggle with difficult emotions, thoughts,
sensations, and impulses.
Now notice all of the experiences that have shown up today—particularly
the difficult thoughts and feelings of your “worst self.” And as
you do, notice that you’re here now, watching all of it. See if you
can make space to be the observer right now. You are exactly who
you should be. Nothing needs to be changed. Nothing needs to be
fixed.
This visualization goes to the heart of ACT: developing a new
relationship with private events. It helps clients learn to observe thoughts
and feelings, rather than being drawn into maladaptive interpersonal
behavior. While clients can’t stop the thoughts and feelings that arise as
manifestations of childhood trauma and conditioning, they can learn to
watch these private experiences with detached nonjudgment while choosing
to act on valued intentions, rather than reacting with old coping behaviors.

Dropping the Rope

Dropping the Rope is an experiential exercise that combines exposure
with lessons about behavioral flexibility. You’ll need a somewhat short
piece of rope—about six feet long—for this exercise. Here are the specific
steps:

1. Ask about a recent schema-triggering situation and have the client

describe the associated feelings and thoughts, then objectify this
schema-related pain by asking questions about its shape, size, color,
weight, texture, and so on. You can also ask whether any of these
 physical qualities are changing or whether the pain is moving in any
way.

2. When the client has clearly described the schema-related pain as an

object, explain that you’re taking the object out of him or her and
putting it in you. Act out this process of transferring the pain.

3. Hold one end of a rope and ask the client to hold the other end. Then
inquire about how the client has been relating to this pain when it
shows up.

4. Pull on the rope and let the client struggle with you as the schema-
related pain. Remind the client of the feelings and thoughts. Pull the
client around or let the client try to get away by pulling you for a
minute or two.

5. Encourage the client to explore alternative solutions. If necessary,

suggest dropping the rope.

6. After the client drops the rope, continue to represent the pain and
follow the client around wherever he or she goes.

7. Help the client notice that even after he or she drops the rope, the
schema-related pain is still there. However, the client is now free to
move around, including toward important values. Even though the
pain is still there, the client is setting the direction rather than being
constrained and locked in a struggle.

Clients may not arrive at the idea of dropping the rope on their own.
You may need to guide them to this solution, as in the following dialogue.
The client in this exchange has a subjugation schema that’s been activated
by her relationship with her roommates. She has trouble with their low
standards of cleanliness in the kitchen and bathroom but hasn’t mentioned
this because she believes that the feelings of others always come first.
Recently she got up the nerve to schedule a meeting to discuss the problem.
However, doing so set off fear that she’ll be asked to move out, along with
schema-driven thoughts, such as “After this they won’t even talk to me,”
“I’ll have to find another place to live,” and “I can’t stand the mess, but I’d
better not rock the boat.” As the dialogue begins, client and therapist are
holding either end of the rope:
Therapist: (Pulls.) Okay, I’m the fear. I’m the thought that they won’t even
talk to you and that you’ll have to find a new place to live. (Pulls
the rope harder.) What are you going to do? This is a big worry, a
big struggle.
Client: (Pulls on her end.) I don’t know. I hate this. I’m always so afraid—
afraid to say what bothers me.
Therapist: (Starts to pull the client out of her chair.) I’m pulling you. You
have to come with me wherever I pull you. You can’t do what you
want to do. They’re going to kick you out… They won’t even talk
to you…
Client: What am I supposed to do?
Therapist: I don’t know. What are your choices? (Pulls hard.) You can go
where I take you. Just be quiet and don’t rock the boat.
Client: I don’t want to do that.
Therapist: Okay. But I’m going to keep pulling you around anyway. I’m
your fear and your thought that they’ll reject you. (Pulls the client
in one direction after another.)
Client: Hey, I could drop the rope. (Lets go of the rope.)
Therapist: How does that feel? Go ahead; move around.
Client: I feel freer.
Therapist: (Following the client closely.) Look at what’s happening. Even
though you dropped the rope, the schema-related pain is still
there. It’s close by. But notice what it feels like to have it there
without the struggle to get away or to fix it, without wondering
whether to speak up or be quiet. Notice how, when you aren’t
struggling with the rope, you have more freedom to choose where
you want to go.
Client: Yeah, now I can move anywhere.
Therapist: Notice how your hands and feet are no longer occupied and you
can choose your path. The pain is still there, but it isn’t
controlling your destination anymore.

Summary
In essence, this book’s approach to recurring, schema-driven interpersonal
problems revolves around two key processes: clarifying values and then
committing to specific values-based intentions. As long as clients are able
to move in the direction of their values, the work remains action oriented.
But when cognitive and emotional barriers show up, the focus must shift to
exposure and defusion. At the end of every exposure or defusion exercise,
it’s important to bring the focus back to willingness. Would clients be
willing to carry difficult feelings or thoughts with them as they act on
particular intentions? Would they be willing to have all of the experiences
that come up as they choose to relate to others based on their values? If the
answer to these questions is yes, the focus can shift back to planning and
acting on valued intentions. If the answer is no, you’ll need to continue to
work on barriers using exposure and defusion techniques.
In the end, what matters is that clients be free to choose how they relate
to others, rather than letting schema-driven affect, thoughts, and behaviors
choose for them. The goal is to help them learn to watch the pain—waves
of fear or shame, seemingly endless streams of frightening or judgmental
thoughts—and still act in ways that support the relationships they care
about.
 Chapter 8

Working with Six Key Processes

This chapter covers common treatment issues that come up in both
individual and group therapy for interpersonal problems and gives some
suggestions on how to address them. There are six processes integral to this
treatment, and all will arise throughout the treatment process, regardless of
the order presented in the protocol:

Creative hopelessness and workability

In-session activation of schemas

Activation of schemas in day-to-day life

Values-based planning

Defusion

Exposure

All of these processes are recurring features of treatment, and the

therapy will continue to cycle through them. Learning how to navigate
these processes and when to implement them is critical to good outcomes.
In this chapter, we’ll focus on five aspects of each key process:

1. How to recognize when to use the process—the distinguishing cues

or signals that indicate that a particular process is appropriate

2. How to discuss the process with clients—how to label and introduce

the process in therapy

3. Criteria to help guide treatment choices

4. Key techniques for implementing the process in therapy

 5. Common problematic client reactions and how to respond

Note that the criteria section (item 3) will help you determine whether
you need to work on other processes before continuing with the key
techniques outlined in the next section. If the issues mentioned in the
criteria section don’t apply to a given client, you can proceed to implement
the techniques and strategies discussed in the next section (item 4, on key
techniques for implementing the process in therapy).

Creative Hopelessness and Workability

Creative hopelessness is a critical process in therapy, and one that
reemerges quite often. This process is especially crucial for getting a “buy
in” for treatment. If clients don’t accept that avoidance and control are the
problem and the target of treatment, you can’t proceed with the approach in
this book. These clients won’t have the willingness and motivation to
experience the difficult schema-related pain that comes up during exposure
and values work, yet this pain must be accepted if clients are to take steps in
valued directions. Therefore, throughout therapy it is critical to remind
clients of the long-term costs of old coping behaviors and help them
recognize that schema-related pain is unavoidable.

1. Recognizing When to Use Creative Hopelessness and Workability

Several key signals can alert you that working with creative
hopelessness and workability would be timely and appropriate:

When clients are attempting to avoid or change a difficult

private experience. Clients may say things like “I just want to feel
like I belong; I don’t want to feel so lonely and different” or “I want
to feel less depressed.”

When clients are using schema coping behaviors. Clients may use
schema coping behaviors in session with the therapist, or they may
describe situations when they have recently used a schema coping
behavior in a relationship outside of session. If a client pushes you
away, creates distance, minimizes the importance of the relationship,
 or gets angry with you in session, this may be a schema coping
behavior. Also be alert to instances when clients describe these
kinds of behaviors outside of therapy, saying things like “I yelled at
her,” “I didn’t go to the job interview,” or “I kept calling her over
and over again and she wouldn’t pick up.”

When avoidance was a barrier to following through on values-

based intentions. Clients may reveal this by saying things like “I
didn’t tell her how I felt because I felt too guilty” or “I didn’t do the
homework you assigned because it made me too anxious.”

2. Discussing Creative Hopelessness

First, work with clients to identify all of the different ways in which
they have attempted to avoid or get rid of particular feelings, thoughts, or
experiences connected to their schemas. Help them assess the costs of
avoidance, including both short-term and long-term outcomes. Creative
hopelessness hinges on recognizing that schema-related pain is unavoidable
and that attempting to avoid it only leads to more pain and suffering in the
long run.

3. Criteria to Guide Treatment Choices Regarding Creative

Hopelessness
If clients don’t accept that their schema-related pain is unavoidable, use
the strategies in the next section, on key techniques, to help develop
willingness to experience primary pain. Likewise, if clients don’t recognize
that schema coping behaviors only work temporarily and then make things
worse in the long run, again use the strategies in the next section to help
engender creative hopelessness. Once clients accept these two key points,
proceed to assessing barriers to alternative behaviors and working on
exposure, defusion, and values clarification to help them face their barriers.

4. Key Techniques for Cultivating Creative Hopelessness

There are several effective techniques for helping clients arrive at the
difficult but pivotal place where they experience creative hopelessness.
Start by identifying their maladaptive coping behaviors and avoidance
strategies. For example, you might ask about a specific incident, saying
something like “What did you do when you felt this mistrust or fear that
this person will leave you?” Or you might ask a more general question, like
“How do you usually behave when you feel this fear?”
Next, explore the outcome of old coping behaviors. For example, you
might ask, “What happened after you called her again and again? What was
the outcome? How did she respond? Did you feel better or worse?” Once
you’ve established that schema coping behaviors haven’t managed to
permanently remove this pain and have actually led to more pain, help
clients realize that the primary pain is unavoidable and is in them. Suggest
that they don’t have to remove this pain in order to behave differently and
that perhaps the answer lies in relating to this pain differently: getting closer
to it and more curious about it rather than running away from it.
Finally, connect all of these schema-related experiences, and especially
the costs of old coping behaviors, to various relational domains and a
variety of past experiences. Here are some examples of questions you might
ask: “How many times did this feeling of deprivation come up for you with
your partner yesterday?” “How many times did this come up with your
friends over the past week?” “How many times did this come up at work
over the past month?” Help clients notice that this feeling has been with
them for a long time and may be unavoidable. You might ask something
like “Could it be that every time you take a step toward being more intimate
with someone, this fear that the person will leave you will come up, along
with the urge to create distance and disconnect?”

5. Responding to Problematic Client Reactions to Creative

Hopelessness
When trying to arrive at creative hopelessness, the most typical
problematic reaction is when clients can’t accept that their primary pain is
unavoidable and therefore continue to try to eliminate and decrease this
pain. In this case, you can have a discussion about avoidable versus
unavoidable pain, including the things we can and cannot control. You can
also describe the relationship between primary and secondary pain. To this
end, help clients notice the specific ways that avoidance makes their pain
worse in the long run.
You can use specific creative hopelessness metaphors, such as the
quicksand metaphor or the metaphor of digging a hole (described in chapter
4), or you can simply ask clients about it directly, saying something like
“Check in with your own experience. Have you ever managed to
permanently get rid of this feeling? Have you ever been able to permanently
eliminate or control the thoughts and feelings connected to your schema?”
You can also bring up commitment, saying something like “Would you
be willing to have this feeling of shame if it brings you closer to being the
honest and genuine person that you want to be? Would you be willing to
bring this feeling of shame with you and still express your needs in the
relationship?”

Activation of Schemas in Session

Schemas are frequently triggered in session in both individual and group
therapy. For example, clients who have a defectiveness schema will feel
criticized by the therapist. In group therapy, they will also sometimes feel
criticized by other group members or by the group in general. These
incidents provide an excellent opportunity to respond to schema activation.
Help clients notice when their schemas are triggered in session and how
they react. Work with them to identify the schema and the trigger and to
label various aspects of their experience, including thoughts, emotions,
sensations, urges, and behaviors connected to the schema, with a particular
focus on schema coping behaviors. The objective is to help clients become
increasingly mindful of schema-related experiences, especially the costs of
their typical coping behaviors, to help build motivation to choose to
respond differently in their relationships.
It’s worthwhile to take every opportunity to connect clients’ in-session
coping behaviors to outcomes of these coping behaviors in other
relationships. This is a powerful move because it provides an opportunity
for clients to practice acceptance of schema-related pain in the service of
values-based behavior.
1. Recognizing In-Session Activation of Schemas
There are a couple of key signals that indicate a schema has been
triggered in session:

When clients show strong affect. If clients seem to be feeling

angry, ashamed, embarrassed, guilty, disappointed, or afraid, this
may indicate schema activation.

When clients use a schema coping behavior with you. Watch for
times when clients create distance, seek reassurance, get clingy,
withdraw, become submissive, or blame, attack, or avoid you.
Schema coping behaviors may also show up in the form of
explaining or justifying their behavior or getting defensive.

2. Discussing In-Session Activation of Schemas

When introducing schemas and identifying which schemas are relevant
to clients, explain that everyone has schemas, including you, the therapist.
Also explain that it’s inevitable that schemas will sometimes be triggered in
the course of therapy. As you work with clients to identify the thoughts,
feelings, sensations, and urges that come up when the schema is triggered,
don’t be attached to labels and descriptions from this book (or elsewhere).
It’s often a good idea to use clients’ language to describe and label their
schema experience.
Also, seek permission from clients to point out moments when their
schemas have been activated in session, and ask them to try to notice and
point out those moments as well. Ask for permission to stop them in
moments when identified schema coping behaviors occur in the room.
Predict that, although this will be an uncomfortable experience, this
exposure to schema affect will be an important part of treatment. Point out
that there’s something positive about these situations, in that they provide
opportunities to learn about their schemas and coping behaviors and to try
out new behaviors.

3. Criteria to Guide Treatment Choices Regarding In-Session

Activation of Schemas
 If clients can’t recognize when their schemas have been triggered, use
the strategies in the next section, on key techniques, to help them notice that
this is happening. If they do generally notice when this is occurring,
proceed to assessing barriers to alternative behaviors and working on
exposure, defusion, and values clarification to help them face their barriers.
If clients aren’t aware of potential triggers that may activate their
schemas, use the Interpersonal Triggers Worksheet from chapter 4 to help
them identify people and events that commonly trigger their schemas.
If clients haven’t accepted that schema-related pain is unavoidable, shift
the focus back to creative hopelessness.
If clients can’t identify and bring mindful awareness to their schema-
related experiences (the thoughts, feelings, urges, sensations, and memories
that come up when schemas are triggered), shift the focus to developing
mindfulness.
If clients are highly fused with their schema content, it’s probably a
good idea to work on defusion techniques.
If clients haven’t recognized that avoidance is creating distance from
their values, shift the focus to values clarification and committing to values-
based action to help them differentiate how they have been interacting with
how they would like to be in relationships.
If clients don’t have much willingness to experience their schema-
related pain, work on creative hopelessness and values clarification.

4. Key Techniques for Working with In-Session Activation of Schemas

Mainly at the beginning of treatment, but sometimes later, you’ll need
to help clients recognize moments when their schemas have been triggered.
Ask them about it directly. Here are some examples: “I’m wondering if
you’re feeling controlled right now, like you have no choice.” “Are you
feeling like I’ve shamed you somehow?” “It seems like you’re feeling as
though I don’t get you—maybe even deprived, like I won’t meet your
needs. Does it seem that way to you?” Then explore which schema was
activated, the thoughts and emotions that came up for clients in the
moment, and any coping behaviors they are using.
 Next, link clients’ in-session activation of schemas to similar situations
in various interpersonal domains; for example, “Do you notice how the
same feeling that comes up between you and your girlfriend—where you
feel like you’re the bad guy and will be blamed and punished—is coming
up for you right now with me?”
Also identify the coping behaviors clients are using with you and then
connect those to coping behaviors they use in other relationships; for
example, “It seems like you’re trying to explain or justify yourself right
now, as if you feel you’ve done something wrong. Does it feel that way to
you?” or “I wonder if your pattern of being late to therapy is similar to the
coping behavior we identified that you use with your boyfriend, where you
create distance and withdraw in order to protect yourself from feeling
abandoned. Do you think that may be coming up in here?”
In a group setting, you can ask either the person whose schema has been
triggered or other group members which schema they think has been
activated and then explore what the trigger might have been. However,
when inviting other group members to comment on one person’s schemas
or schema coping behaviors, be sure to encourage the group to relate to the
experience, normalize it, and explore it compassionately.

5. Responding to Problematic Client Reactions to In-Session Activation

of Schemas
After clients become more aware of their schemas and the costs of old
coping behaviors, they may still have difficulty behaving differently. One
possible reason for this is that they don’t notice the opportunity to behave
differently. Another probable factor is that they habitually attempt to avoid
their schema-related pain, whereas staying in contact with this pain is
necessary for behavioral change. Here are a few strategies that may help:

Increase clients’ exposure to schema affect and have them notice the
moment when urges to engage in old coping behaviors come up for
them. You can do this via visualizations of recent schema-triggering
events and keeping clients immersed in the schema experience.
Methods for keeping them in contact with schema experience
include mindful breathing, identifying sensory experiences in the
moment, and recognizing the current behavior as an avoidance
 strategy. For example, you could say, “What would it be like to stay
with this feeling that you’ll never feel that your partner understands
you or will meet your needs? What is that experience like? Where
do you feel that in your body?”

Help clients recognize the moment of choice by pointing out that a

schema coping behavior just occurred in the room, identifying what
happened to trigger the schema, and exploring the thoughts,
feelings, and urges that led to the schema coping behavior.

When clients use old coping behaviors in session, identify the

coping behavior and help them come up with alternative responses.
For example, if a client says that feeling deprived or misunderstood
creates an urge to demand or explain, explore alternative behaviors
they can engage in when they have that urge, such as express a
feeling, state some sort of appreciation, or write about their
experience in a journal.

Provide positive reinforcement when clients display new behaviors

in session. Either directly or indirectly, acknowledge that they used
a different behavior.

Working with Activation of Schemas in Day-to-Day

Life
When clients describe problematic interpersonal interactions in day-to-day
life, help them figure out whether schema activation played a role in the
difficulty. Explore which schema may have been activated and what the
trigger was. Then have them label various aspects of the experience,
including thoughts, emotions, sensations, urges, and behaviors connected to
the schema, with a particular focus on schema coping behaviors. As with
in-session activation of schemas, the objective is to help clients become
increasingly mindful of schema-related experiences, especially the costs of
their typical coping behaviors, to help build motivation to choose to
respond differently in their relationships.
1. Recognizing When Schemas Have Been Activated out of Session
There are a couple of key signals that indicate clients’ schemas were
triggered in day-to-day interactions:

When clients describe a situation where they used schema

coping behavior. Watch for stories about interpersonal interactions
that include clients’ schema coping behaviors, such as giving in,
demanding, distancing, attacking, or withdrawing.

When clients have strong affect while telling a story. Watch for
times when clients display strong anger, sadness, shame, guilt, or
embarrassment while describing interpersonal interactions.

2. Discussing Schema Activation in Day-to-Day Life

When clients report day-to-day interactions that seem schema related,
ask directly whether they think a schema was triggered. If they aren’t sure,
suggest some possible schemas; for example, “As I listen to you describe
this situation with your wife, I’m wondering if that ‘bad guy’ feeling was
triggered for you at that time.”
Also help clients identify the problematic coping behavior. For example,
you might ask, “What did you do in that moment when you felt deprived?
How did you behave?” In situations where clients didn’t actually fall back
on old coping behaviors, ask about any urges; these can provide insight into
clients’ typical maladaptive behavior patterns.
Finally, and crucially, identify the impact and cost of the coping
behavior in clients’ relationships; for example, “What happened after you
withdrew? Did the relationship feel better or worse? What did the other
person do?”

3. Criteria to Guide Treatment Choices Regarding Schema Activation

in Day-to-Day Life
If clients haven’t accepted that schema-related pain is unavoidable, shift
the focus back to creative hopelessness.
 If clients understand and accept that the pain is unavoidable but still
continue to employ old coping behaviors in day-to-day interactions, shift
the focus to values clarification and committing to values-based action to
help them differentiate how they have been interacting with how they
would like to be in relationships. Also help them notice the various
moments of choice to behave differently by slowing down the story and
identifying the specific thoughts, feelings, or urges that were driving their
behavior. Assist them in identifying alternative behaviors to engage in at
those times.

4. Key Techniques for Responding to Schema Activation in Day-to-Day

Life
If clients are to choose to behave differently when their schemas are
activated, they must be able to notice triggering situations as they occur or,
better yet, be able to foresee that certain situations may activate their
schemas. The Schema Events Log and Schema Triggers Worksheet, both in
chapter 2, began to build these skills, and the Schema Coping Behaviors
Worksheet, in chapter 3, helped them identify the coping behaviors they
tend to use in specific situations. The Interpersonal Experiences Diary, from
chapter 4, brings all of these skills together and allows clients to identify
signals that can serve as indicators that a schema has been activated.
In session, use entries from the Interpersonal Experiences Diary to
conduct in-session visualizations bringing clients back into salient
situations. Have them observe all aspects of the interaction or situation,
including emotions, thoughts, physical sensations, and schema-driven
urges. Then ask what they actually did and whether they resorted to
problematic coping behaviors.
Focus on the moment of choice—that key point when a schema has
been activated but clients haven’t yet responded. This is the time when they
can choose to engage in values-based behavior rather than old coping
strategies. Help them identify and list signals that will allow them to
mindfully recognize that they’ve reached this critical point. These signals
include both triggering situations and the resulting emotions, thoughts,
sensations, and urges. These can serve as red flags that a schema has been
activated, providing an opportunity to take advantage of the moment of
choice.
You can help clients notice the moment of choice by slowing down the
story and identifying moments when they could have chosen a different
behavior. For example you can point out that any time they have an urge to
criticize their partner, they can choose to appreciate their partner instead, or
that any time they have the thought that they want to end their relationship,
they can hug their partner instead. Help clients identify specific thoughts,
urges, or feelings that drive them to use a particular schema coping
behavior and then explore alternative, values-based behaviors they can
engage in instead.

5. Responding to Problematic Client Reactions to Schema Activation in

Day-to-Day Life
As mentioned in regard to in-session schema activation, even after
clients become more aware of their schemas and the costs of old coping
behaviors, they may still have difficulty behaving differently. The approach
outlined above will help them identify the moment of choice, but even then
they may struggle to engage in new behaviors. In this case, work with
clients to identify specific new responses to replace old coping behaviors.
You can use role-playing exercises based on recent triggering situations
to help clients practice these new behaviors. For example, you might play
the role of the client’s critical mother and have the client notice his or her
experience and urges and practice responding differently.

Values-Based Planning
Values-based planning is an integral component of treatment and will
reemerge frequently throughout therapy. Clients who are struggling with
recurring interpersonal problems are often unclear about their values in
relationships or how they’d rather be interacting. Their behaviors in
relationships have mainly been driven by the desire to avoid schema-related
pain and feared outcomes.
Once clients understand the costs of maladaptive coping behaviors,
values-based planning can begin. Help clients identify key interpersonal
values in all relevant interpersonal domains, then use these as the basis for
developing specific intentions. Work with clients to review past triggers and
predict future situations where they can engage in their new, values-based
behaviors.
As therapy proceeds, frequently check in about whether clients’
behaviors are consistent with their values. When they resort to old,
maladaptive coping behaviors, help them notice and label what’s going on
and assess the costs while also reminding them of their commitment to new
ways of responding. From time to time, review the effectiveness of current
intentions based on previous outcomes and new or evolving issues in
relationships and help clients plan new values-based actions as appropriate.
Because a crucial aspect of values is that they are personal and freely
chosen, it’s essential that you keep clients’ stated values in mind and
effectively discriminate between avoidant and values-based behavior.

1. Recognizing When to Use Values-Based Planning

Several key signals can alert you that values work would be timely and
appropriate:

When clients use maladaptive coping behaviors in session. This

can show up in several forms. Clients may make demands of you,
minimize the importance of the relationship, attempt to quit therapy,
seek reassurance, worry about you, comply with all of your
interventions and statements, or blame or attack you.

When clients tell you a story about using maladaptive coping

behaviors in day-to-day life. Clients may say things like “I yelled
at my husband,” “I ignored her,” “I kept trying to explain,” “I told
him he’s a jerk,” or “I kept insisting that she listen to me.”

When clients are about to enter a previously identified

triggering situation. An example is a holiday dinner with a critical
mother, an interaction with a demanding boss, or needing to set
limits and boundaries with a child who’s acting out.
2. Discussing Values-Based Planning
Explore the costs of old coping behaviors. Directly ask whether specific
behaviors moved clients closer to or farther away from their values and
whether the behavior made the relationship feel better or worse. You can
also explore the costs of problematic coping behaviors in the therapeutic
relationship and whether something similar is occurring in other
relationships. For example, you might say, “When I notice you withdrawing
and disconnecting in session with me, it feels like it creates distance
between us and I feel confused about what’s going on for you. Do you think
that withdrawing creates distance in your relationship with your boyfriend
as well?”
Help clients explore how they can behave differently both in session
and in day-to-day life. Continuing with the previous example, in session
you might say, “So, in those moments when you’re triggered and get the
urge to withdraw and disconnect from me, how can you let me know what’s
going on for you? What could you do differently to bring yourself closer to
your value of being intimate and expressive in relationships?” Then you can
extend this to clients’ key relationships; for example, saying “In those
moments when you feel rejected by your boyfriend and you get the urge to
run away and disconnect from him, what can you do to let him know what’s
going on for you? What can you do or say that will bring you closer to
being the expressive and open person you want to be in your relationship?”
Remind clients of the barriers to valued action that you’ve previously
identified and ask them whether they’d be willing to have those difficult
thoughts and feelings while taking action on their new, values-based
intentions.

3. Criteria to Guide Treatment Choices Regarding Values-Based

Planning
If clients aren’t clear on their interpersonal values, use the Valued
Intentions Worksheet in chapter 5 to help them clarify their values. If they
aren’t clear on the thoughts and feelings that act as barriers to their values,
use the Assessing Barriers Worksheet in chapter 5 to explore and identify
barriers. If clients aren’t willing to feel the emotional pain that comes up as
they act on valued intentions, focus on creative hopelessness to build
willingness or use exposure and defusion techniques to help clients accept
and tolerate their primary pain.

4. Key Techniques for Implementing Values-Based Planning

After helping clients identify key values in relevant interpersonal
domains, to work collaboratively to identify values-based intentions:
specific behaviors that would reflect those values in current relationships.
One way to identify specific values-based intentions is by exploring clients’
schema-related pain, thoughts, and coping behaviors. These often reveal a
lot about clients’ values. For example, someone with an abandonment and
instability schema who copes by disconnecting, withholding, and distancing
from others may describe not wanting to be vulnerable and intimate with
people for fear of being abandoned. This may reveal a desire for connection
and intimacy. This information can be used to explore specific intentions
related to being vulnerable and expressing feelings in relationships. Another
example would be a client with a defectiveness schema who fears
disappointing others and who copes through compliance and surrender. This
may reveal a value of being more authentic, genuine, and assertive in
relationships. In this example, you could even ask something like “What if
you could be 100 percent certain that your husband would never abandon
you—how would you behave differently? Would you be more honest or ask
for what you want more often?”
Another way to use clients’ schema-related pain to identify potential
values-based intentions is similar to the exercise Exploring the Flip Side,
from chapter 7. Write clients’ schema-related thoughts and feelings on one
side of a piece of paper and then, on the other side, list what these thoughts
and feelings have stopped them from doing. This helps clients identify
specific values-based intentions while also clearly illustrating the costs of
avoidance.
Once values-based planning commences, help clients come up with
specific intentions for the week and also underscore that these new
behaviors are alternatives to their old schema coping behaviors—that these
are behaviors to be used when they experience that moment of choice, when
they have the opportunity to respond by moving in valued directions rather
than reacting in habitual ways.
5. Responding to Problematic Client Reactions to Values-Based
Planning
A common problem when doing values work is clients being overly
invested in the outcome of a particular intention (something they cannot
control), rather than being invested in taking the steps toward being the kind
of person they want to be (something they do have control over). In this
case, a hoped-for outcome is driving clients’ behavior more than values are.
For example, a client with a subjugation schema may have an intention to
express particular needs to his or her partner but not follow through because
of fear that the other person will get mad or feel hurt. Here are some
strategies to use in such situations:

Help clients defuse from stories about ideal and feared outcomes.

Help clients recognize that ideal or feared outcomes are connected

to their schemas—that they exist in the mind and not in the world.

Assess the function of the stories and whether the desire for a
particular outcome is moving clients closer to or farther away from
their values.

Return the focus to the value and reassess its importance, as well as
the costs of not acting on this value in relationships.

Revisit the topic of what we can and cannot control. Help clients
notice that, no matter what the outcome, by acting on their
intentions they are getting closer to their values and how they want
to relate to others. Remind them that we can’t control how others
will respond; we can only control how we conduct ourselves.

Explore creative hopelessness in regard to the pain that clients are

trying to avoid.

Do exposure work with any schema affect that clients are trying to
avoid.

Defusion
Defusion techniques create distance from cognitive barriers and promote
willingness to have schema-driven thoughts in the service of acting on
values-based intentions. To begin this work, help clients recognize that
painful thoughts have been barriers to acting on their values and suggest
that in order to relate to others differently they must learn how to relate to
their thoughts differently.
A wide variety of exercises, metaphors, and other strategies can be
employed to help clients with defusion, and chapter 6 provides a great deal
of guidance on these approaches. However, defusion is also a stance that
you should model in how you relate to clients and their thoughts. Take
every opportunity to notice clients’ schema-related verbal behavior,
including thoughts, memories, stories, explanations, justifications, reasons,
interpretations, and assumptions, then model a defused stance by bringing
awareness to the process of thinking by labeling these behaviors as
thoughts, memories, stories, explanations, and so on, and by holding them
lightly. Holding clients’ verbal behavior lightly involves labeling it for what
it is and suggesting alternative thoughts, explanations, and reasons. You
might also connect particular thoughts and explanations to specific schemas
and past experiences or identify the function of the verbal behavior in the
moment. For example, you might say, “That’s an interesting explanation.
What schema is that reason connected to?” or “How is having this rule
working for you? To me, it seems like one of those deprivation thoughts
that pulls you toward making demands.”
Note that although defusion and exposure are discussed separately in
this section, in practice they often go hand in hand and are conducted
simultaneously. As soon as clients begin to defuse from schema-related
thoughts, schema affect typically shows up. And as soon as schema affect
shows up, it triggers schema-related thoughts. Therefore, it’s often
necessary to alternate between defusion and exposure techniques or to work
on defusion and exposure simultaneously.

1. Recognizing When to Use Defusion

There are a couple of key signals that can alert you that defusion work
would be timely and appropriate:
 When clients bring up thoughts connected to their schemas. This
includes stories, explanations, predictions, worries, reasons, and
judgments. Here are some examples: “I’m just going to fail at
whatever I try.” “She always makes me feel bad.” “I don’t trust
him.” “I’m ugly.” “I disappoint people.” “I never get it right.” “It’s
because he’s too selfish.” “She broke up with me because I’m
boring.”

When clients bring up schema-related stories about other

people’s behaviors. This includes assigning motives or intentions to
others and predictions about how others will respond: Here are some
examples: “She’ll just end up hating me and leaving me.” “He’s
going to cheat on me.” “She’ll get angry if I express how I feel.”

2. Discussing Defusion
As mentioned, chapter 6 provides a wide variety of techniques for
cognitive defusion, and working with these will go a long way toward
helping clients understand and cultivate this skill. In addition, call attention
to mental activity, thoughts, and stories connected to clients’ schemas using
such phrases as “You’re having a prediction that…” or “Your mind is telling
you a story that…” Look for opportunities to externalize clients’ mind,
saying something like “What’s your mind saying to you about that
situation?” You might even give the client’s mind a name, choosing a name
other than the client’s. For example, with a client named Rebecca, you
might establish the name Suzie for her mind and then sometimes say “What
is Suzie telling you to do?” or “That sounds like something Suzie would
say.”
Also try to connect particular verbal behaviors associated with clients’
schemas to all the different domains in which they show up. This helps
clients see that schema thoughts show up across different relationship
domains—an indication that they exist inside the client, rather than being
specific to particular relationships or interactions. For example, if clients
have a frequent thought related to their partner not meeting their needs or
not understanding them, you can help them notice the many different
relationships where that thought comes up—with their boss, with their
mother, and so on. Alternatively, ask them to them recall the first time this
thought came up for them in a relationship or point out times when that
thought has come up in regard to you, the therapist.

3. Criteria to Guide Treatment Choices Regarding Defusion

Defusion strategies can be used with most of the cognitive content that
clients bring up. The only case in which you might delay defusion is with
thoughts that describe an outcome of a particular schema coping behavior.
For example, consider a client who brings up a thought that she believes her
husband is thinking about divorcing her. Before jumping in with defusion,
you want to assess the workability of her schema coping behaviors and help
her understand how this thought drives her to behaviors that may actually
lead to being abandoned. If she copes with her abandonment and instability
schema through constantly accusing, clinging, and seeking reassurance
from her husband, then it’s likely he may indeed be feeling frustrated with
her. In this situation, it would be better to use strategies that focus on
creative hopelessness or values. You could also work on creative
hopelessness, values, and defusion simultaneously by helping the client
recognize that the thought “He’s going to divorce me” pulls her toward
using coping behaviors (such as accusing or blaming) that maintain her
abandonment schema and pull her farther away from her values. It’s critical
to distinguish between thoughts that predict actual likely outcomes of the
client’s coping strategies versus fusion with thoughts that block values-
based behavior. For the former, start with assessing the workability of
behaviors and values clarification before moving into defusion; for the
latter, defusion would be appropriate.

4. Key Techniques for Implementing Defusion

When you notice clients buying into a particular explanation or
interpretation, work with them to develop several alternative explanations
or interpretations for the same event, then help them notice that they can
arbitrarily choose which explanation or interpretation they decide to buy
into. In a group setting, you could also ask other group members for
alternatives and use this to lead into a discussion of how different people
are more likely to buy into certain thoughts depending on their schemas.
 Discuss the function of schema-driven thoughts with clients. To this
end, you might say something like “Once a schema gets triggered, many
thoughts will serve the purpose of avoiding schema-related pain. These
thoughts will try to pull you toward using old coping behaviors and running
away from the difficulty.” Explain that schema-related thoughts are often
strongest when people start taking steps toward their values. Encourage
clients to notice the function of their thoughts whenever they take steps in
valued directions. You might ask something like “When you started acting
on your intentions this past week, what did you notice your thoughts trying
to do? How were they pulling you to behave? What was their goal or
purpose?”
Ask clients whether they are willing to have difficult or painful thoughts
in the service of acting on their values. Here are a couple of examples:
“Would you be willing to have the thought that your girlfriend will get
angry if you express yourself and still let her know that your feelings were
hurt?” “Would you be willing to have the thought that your husband is
selfish and unable to meet your needs and still ask him to give you a ride to
work on Tuesday?”
In a group setting, you can ask group members to label schema-driven
thoughts that come up for individuals during the session; for example,
“What kind of thought is that—a predicting thought, a judgment, an
explanation?” or “What schema might that thought be connected to?”
Encourage the group to notice which thoughts and stories are connected to
which schemas. Also encourage group members to notice judgments and
label them as such.
In a group setting, you might also ask group members how they think a
particular thought is working for one group member—whether that thought
moves the person toward or away from his or her interpersonal values. You
could even ask other group members how strongly they believe or buy into
a particular thought, story, or explanation that one group member has
expressed.

5. Responding to Problematic Client Reactions to Defusion

A common problematic issue that arises with clients regarding defusion
is that they are so fused with the content of their thoughts that they view
these thoughts as reality, which leads them to want to understand their
thoughts rather than create distance from them. Clients believe that these
thoughts represent a truth about themselves or their problems and that
analyzing and assessing these thoughts will help them change their
behavior, understand who they are, solve problems, or predict and prevent
certain outcomes and patterns. Here are some strategies to use in such
situations:

Help clients notice how particular thoughts act as barriers to values.

Discuss the difference between problem solving and ruminating,

worrying, and fusion. Explore which thoughts are productive, bring
clients closer to their values, and help them solve problems, and
which thoughts are repetitive, damaging schema-driven thoughts.

Explore whether these thoughts have brought clients closer to

solving a particular problem or have helped change their behavior,
and whether realizations necessarily lead to behavioral change.

Assess the workability of holding thoughts too tightly and whether

particular thoughts make clients feel better or worse.

Explain that we don’t have to defuse from all of our thoughts, that
defusion is just a choice we have in the moment. We can let our
minds control us, or we can choose to create distance from mental
content and hold it lightly. It’s an option, not a strategy to use with
every negative thought.

Exposure
Emotion exposure techniques promote willingness to face schema-driven
affect. The goal of exposure is to help clients build acceptance of
unavoidable schema-related pain and willingness to have that pain in the
service of acting on values-based intentions. To begin this work, help
clients recognize that painful emotions have been barriers to acting on their
values and suggest that in order to relate to others differently they must
learn how to relate to their emotions differently. Exposure is difficult work,
so it’s essential to focus on clients’ key values, which will provide
motivation for them to experience schema-related pain. Be careful to use
exposure only with clients’ primary pain, not the secondary pain due to
maladaptive coping behaviors, which is both avoidable and unnecessary.
As mentioned in the section on defusion, exposure to schema affect will
bring up thoughts connected to the schema. Therefore, when schema-related
thoughts show up during exposure, help clients defuse from those thoughts,
then get back to the emotion. Thoughts that come up during exposure are
attempts to avoid painful schema affect. Much of this aspect of the work
involves carefully balancing defusion and exposure or working with these
two processes simultaneously.

1. Recognizing When to Use Exposure

Several key signals can alert you that exposure to emotions would be
timely and appropriate:

When clients’ schemas are triggered in session. Watch for times

when clients are angry, ashamed, or defensive or express any strong
schema affect.

When clients engage in maladaptive coping behaviors in session

or recount an event where they engaged in those behaviors.
Watch for times when clients seek reassurance, offer justifications,
or are demanding, distancing, compliant, belittling, minimizing, and
so on. Also be alert for stories of behaving in these ways in day-to-
day life.

When clients identify an emotion as a barrier to a values-based

intention. Examples are such statements as “I didn’t express my
feelings because I felt ashamed,” “I didn’t ask for help because I felt
guilty,” and “I didn’t take time for myself because I didn’t want to
be alone.”

When clients display emotionally avoidant behaviors. Examples

of this are ruminating, intellectualizing, and incongruent affect, such
as laughing when talking about a shameful experience.
2. Discussing Exposure
When clients accept that the problem isn’t schema-related pain, but
rather attempts to eliminate or avoid that pain, they are in a position to
experience and explore creative hopelessness. That sets the stage for
discussing exposure. Explain that part of the solution is to get closer to the
pain and relate to it differently, rather than running away from it. As ever,
highlight the many costs of emotional avoidance and suggest acceptance
and willingness as an alternative.
You can use various techniques from chapter 7, such as the exercise
Exploring the Flip Side, to help clients see that the farther away their
schema-related pain is, the farther away their values are. Explain that
schema-related pain will often be part and parcel of acting on their values,
and also acknowledge that exposure is difficult and painful, but also a
necessary step if they are to engage in new behaviors. For example, you
might say something like “It seems like every time this deprivation schema
shows up, it feels so painful and unbearable that you run away from it by
getting angry and making demands. We’ve been discussing that you want to
be able to express your needs nonjudgmentally and calmly with your
partner. It seems that this painful sense of being deprived has stood in the
way of expressing your needs differently. To help you express your requests
calmly and nonjudgmentally, maybe we need to bring up that deprivation
feeling right here, in this room, and really look at it, sit with it, and learn
how to relate to it differently. Maybe that would help you behave differently
when it shows up. Would you be willing to give that a try?”

3. Criteria to Guide Treatment Choices Regarding Exposure

Before conducting exposure, obtain clients’ permission and provide a
rationale for doing so. Always conduct exposure fairly early in the session
so that time remains to process and discuss the experience; otherwise,
clients may leave the session feeling unsettled.

4. Key Techniques for Implementing Exposure

An effective way to conduct exposure is to use imagery with a recent
schema-triggering event. Have clients visualize the situation and events
leading up to the moment when they engaged in old coping behaviors. As
they approach that moment, have them label all of the emotions, sensations,
and urges coming up just before they engaged in the problematic behavior.
Help them identify this as the moment of choice, when they can
differentiate between urges and actions and choose to respond in alignment
with their values. This can provide a visceral experience that they can have
a very strong urge to engage in one behavior and still choose to do
something else.
During emotion exposure, help clients observe and describe their
emotional experience. You might objectify a specific emotion by asking
clients to describe its shape, size, color, texture, and weight, along with
where it is located in the body and any movement of the emotion. You can
also make comments about clients’ nonverbal behavior, such as “Your
shoulders look heavy,” “It seems like you’re holding your breath right
now,” or “Your hands are tightened into fists.” Help them notice all of the
physiological sensations that accompany the emotion.
You can also connect a recent schema-triggering event and the
associated emotions to other situations in the client’s life, including early
childhood memories, and to other interpersonal domains. You can ask
questions like “How many times has this feeling come up for you this
week? How many times this month?” “With whom has this feeling come
up? Can you think of anyone close to you that this feeling hasn’t come up
with?” “Can you remember a time during your childhood when this feeling
came up?” The goal of these questions is to help clients recognize that this
feeling is unavoidable and exists within them, not in external
circumstances. For example, if a client believes that his failure schema gets
triggered only in his current romantic relationship, you can ask him whether
it has ever shown up in other romantic relationships, in relationships with
siblings or parents, or at work.
During any exposure, encourage clients to make space for their
experience and to be compassionate and gentle with it. Here are some
examples of how you might help them create a little more space for painful
feelings: “How much of this emotion are you experiencing right now—40
percent, 70 percent? Would you be willing to have 5 percent or 7 percent
more of this experience if that would bring you closer to acting on your
values?” “See if you can be willing to breathe in just a little bit more of this
pain.” “Can you make the space in your body to have all of your
experience?”
You can also ask clients to put a hand on the part of their body where
they feel their emotional pain and then send warmth and compassion to that
area. Alternatively, have them imagine that their schema-related pain is a
crying baby who needs to be nurtured with soothing kindness. Another
approach is to help clients notice how harsh they’ve been with their own
pain. Than ask them to think about how they would relate to a friend who
was experiencing this pain. Yet another option is to have clients welcome
their schemas out loud; for example, “Welcome deprivation. Welcome
defectiveness.”

5. Responding to Common Problematic Client Reactions to Exposure

A common problem that arises around exposure is that clients have
difficulty remaining in contact with schema affect and the discomfort that
arises for both client and therapist. Clients struggle with staying with the
schema experience, and therapists may have difficulty bringing clients back
to the exposure. The following strategies can be used to help clients build
willingness to stay in contact with schema-related pain:

Explain the rationale for exposure. You can do this using the
exercise Exploring the Flip Side or by working with the monsters on
the bus metaphor. Make sure clients agree that being farther away
from schema pain creates further distance from their values. Also
remind them that schema-related pain is unavoidable.

Clarify clients’ values and reassess the level of importance of values

related to the exposure.

Explore the workability of avoidance through creative hopelessness.

Work with clients to get very clear on the specific costs of their
avoidance of schema-related pain and what impact this has on
particular relationships. Connect specific instances of avoidance or
unwillingness to have pain to specific schema coping strategies that
have been damaging clients’ relationships.
 Assist clients in cultivating self-compassion through mindfulness
exercises.

Use defusion simultaneously with exposure.

Summary
As you can see from how the six processes discussed in this chapter are
interwoven, conducting ACT for interpersonal problems is, by necessity,
very fluid. Always be sensitive and responsive to what’s occurring in the
room in any given moment and be willing to shift focus if that’s what’s
called for. Further, because of the number of potential schemas, the
possibility of multiple schemas, and the many forms schema coping
behavior can take, this approach must also be tailored to the individual
client. Keep clients’ personal values in mind throughout, and be sure to
understand their particular situation, including which emotions tend to be
primary schema affect and which show up as coping behaviors, and in what
situations.
That said, when first using this approach in individual therapy, you may
want to consult the protocol outlined in appendix C for guidance on the
general sequence of events. And even if you won’t be using this approach in
group therapy, we recommend that you read through appendix C to get an
idea of how the processes and techniques might evolve.
Conducting ACT for interpersonal problems can be a delicate balance.
You may have occasional missteps, especially at first. But if you follow
your own values in regard to helping clients overcome schema-related pain
and interpersonal difficulties, you will chart a course toward healing—one
that helps clients enjoy a richer and more satisfying life where their
interpersonal interactions are informed by their values, rather than by early
maladaptive schemas and old coping behaviors that aren’t relevant to
current circumstances. Using the approach in this book, you can help clients
be who they want to be—with friends, family members, lovers, and others
—and this is surely one of the most powerful transformations any of us can
hope for.
 Appendix A

Schema Questionnaire
The following questionnaire, adapted from the Young Schema
Questionnaire with the permission and assistance of Jeffrey Young, PhD, is
useful for determining which schemas are most relevant to clients. The
version below is just for reference. If you wish to use a similar
questionnaire in your practice, please visit schematherapy.com, where you
can purchase the most current version of Jeffrey Young’s questionnaire for
research or clinical use.
Rate the following statements using the scale below:
1 = Completely untrue of me
2 = Mostly untrue of me
3 = Slightly more true than untrue of me
4 = Moderately true of me
5 = Mostly true of me
6 = Describes me perfectly

Abandonment and Instability (ab)

1. I am fearful that people I love will die or leave me.

___________ 2. I get clingy with people when I feel that they are going to leave me.

___________ 3. My support system feels unstable.

___________ 4. I find myself falling in love with people who aren’t capable of or
willing to commit to me.

___________ 5. People have always moved in and out of my life.

___________ 6. When someone I love pulls away, I feel desperate.

 ___________ 7. My obsession with the idea that my lovers will leave me drives
them away.

___________ 8. The people I have the closest relationships with are unpredictable.
Sometimes they are there for me, and sometimes they are not.

___________ 9. I feel like I need people more than others do.

___________ 10. I feel like I will be alone toward the end of my life.

Mistrust and Abuse (ma)

___________ 1. I have the expectation that people will hurt me or use me.

___________ 2. People close to me have consistently abused me.

___________ 3. I know that it is only a matter of time before the people who are
important in my life will betray me.

___________ 4. I must protect myself and be on guard.

___________ 5. People will take advantage of me if I am not careful.

___________ 6. I regularly set up tests for people to determine whether they are
really on my side.

___________ 7. I tend to hurt others before they can hurt me.

___________ 8. I fear that people will hurt me if I allow them to get close to me.

___________ 9. When I think about what people have done to me, I get angry.

___________ 10. The people who I should have been able to trust have physically,
verbally, or sexually abused me.

Emotional Deprivation (ed)

___________ 1. I don’t get as much love as I need.

___________ 2. I feel like no one really understands me.

___________ 3. I am usually attracted to cold partners who can’t meet my needs.

 ___________ 4. I don’t feel connected, even to the people who are closest to me.

___________ 5. I have not had one special person in my life who wants to share
himself or herself with me and cares about what happens to me.

___________ 6. I don’t have anyone in my life to give me warmth, holding, and

affection.

___________ 7. I do not have a person in my life who really listens and is tuned in
to my true needs and feelings.

___________ 8. I find it difficult to let people guide or protect me even though it is

what I want.

___________ 9. I find it difficult to let people love me.

___________ 10. I feel lonely most of the time.

Defectiveness and Shame (ds)

___________ 1. If others really knew me they couldn’t love me.

___________ 2. Because I am inherently flawed and defective, I am not worthy of

love.

___________ 3. I have secrets that I will not share even with the people closest to
me.

___________ 4. I am to blame for my parents being unable to love me.

___________ 5. I present a false self that hides the real me because the real me is
unacceptable.

___________ 6. I tend to be drawn to people who are critical and rejecting of me.

___________ 7. I tend to be critical and rejecting of others, especially those who

seem to love me.

___________ 8. I tend to devalue my positive qualities.

___________ 9. I feel a lot of shame about myself.

___________ 10. Exposure of my faults is one of my greatest fears.

Social Isolation and Alienation (si)
___________ 1. I feel very awkward in social situations.

___________ 2. I don’t know what to say at parties and other gatherings. I feel dull
and boring.

___________ 3. I feel like the people I want as friends are above me in some way,
such as appearance, status, wealth, education, career, or popularity.

___________ 4. I would prefer to avoid rather than attend most social gatherings.

___________ 5. I feel that I am unattractive—too thin, fat, short, tall, ugly, and so
on.

___________ 6. I feel like I am different from other people.

___________ 7. I don’t feel like I belong. I am a loner.

___________ 8. I feel like I am on the outside of groups.

___________ 9. My family was different from the other families when I was growing
up.

___________ 10. I feel like I am not part of the community at large.

Dependence and Incompetence (de)

___________ 1. I feel less like an adult and more like a child when it comes to
dealing with responsibilities of daily life.

___________ 2. I do not have the capability to get by on my own.

___________ 3. I do not cope well by myself.

___________ 4. Other people are better at taking care of me than I am at taking

care of myself.

___________ 5. If I don’t have someone to guide me, I have trouble tackling new
tasks.

___________ 6. I can’t do anything right.

 ___________ 7. I am inept.

___________ 8. I don’t have common sense.

___________ 9. I do not trust my own judgment.

___________ 10. Everyday life is overwhelming to me.

Failure (fa)

___________ 1. I feel that I am less competent than other people.

___________ 2. I feel like a failure when it comes to achievement.

___________ 3. I feel like most people my age are more successful in their work
than I am.

___________ 4. I was a failure as a student.

___________ 5. I feel like I am the least intelligent person in my group.

___________ 6. I feel humiliated by my failures in the area of work.

___________ 7. I feel that I do not measure up in terms of my accomplishments,

and it makes me feel embarrassed around other people.

___________ 8. I feel that people believe that I am more competent than I really
am.

___________ 9. I feel that I don’t possess any special talents that really count in
life.

___________ 10. I work at a level that is below my potential.

Entitlement (en)
___________ 1. “No” is an answer that I have trouble accepting.

___________ 2. When I don’t get what I want, I get angry.

___________ 3. I am special and should not have to accept or be held to normal

restrictions.
 ___________ 4. I always put my needs first.

___________ 5. I have a very difficult time getting myself to stop drinking, smoking,
overeating, or engaging in other problematic behaviors.

___________ 6. I lack discipline when it comes to completing routine or boring

tasks.

___________ 7. I act on impulses and emotions that result in consequences.

___________ 8. When I cannot reach a goal, I become frustrated and give up.

___________ 9. I insist that things get done my way.

___________ 10. My need for immediate gratification can get in the way of my
reaching a long-term goal.

Subjugation (su)

___________ 1. I let other people control me and my life.

___________ 2. I worry that if I don’t fulfill the wishes of others, they will get angry,
retaliate, or reject me.

___________ 3. The major decisions in my life are not in my control.

___________ 4. I have difficulty demanding that other people respect my rights.

___________ 5. I really worry about pleasing people and getting their approval.

___________ 6. I go to great lengths to avoid conflict or confrontations with others.

___________ 7. I give more to others than they give to me.

___________ 8. I experience the pain of other people deeply, which leads me to

take care of the people I’m close to.

___________ 9. If I put myself first, I feel guilty.

___________ 10. I am a good person because I think of others more than I think of
myself.
Unrelenting Standards and Hypercriticalness (us)
___________ 1. I do not accept second best. I must be the best at most of what I
do.

___________ 2. I feel like nothing I do is ever quite good enough.

___________ 3. I strive to keep everything in perfect order.

___________ 4. I need to look my best at all times.

___________ 5. I don’t have time to relax because I have so much to accomplish.

___________ 6. I push myself so hard that my personal relationships suffer.

___________ 7. I put myself under so much pressure that my health suffers.

___________ 8. When I make a mistake, I deserve strong criticism.

___________ 9. I am very competitive.

___________ 10. Wealth and status are very important to me.

Interpreting Your Client’s Schemas

10–19: Very low. This schema probably does not apply to your client.

20–29: Fairly low. This schema may apply only occasionally.

30–39: Moderate. This schema is an issue in your client’s life.

40–49: High. This is definitely an important schema for your client.

50–60: Very high. This is definitely one of your client’s core schemas.
 Appendix B

Research Outcomes
This appendix outlines results of a study of the effectiveness of a ten-
week group therapy ACT protocol for interpersonal problems. (The
protocol used was the basis for the approach outlined in appendix C.) The
randomized, controlled study, conducted by Avigail Lev at the Wright
Institute, used the protocol with a group of forty-four male clients at a
community-based clinic for recovery from substance abuse in Berkeley,
California. Participants were assigned to one of two groups: treatment as
usual (consisting of 22 participants) and the ten-week protocol plus
treatment as usual (22 participants). (Treatment as usual was a day-
treatment recovery program that included 12-step study, relaxation training,
anger management, relapse prevention, and a host of other services.) The
Inventory of Interpersonal Problems (IIP-64; Horowitz, Alden, Wiggins, &
Pincus, 2000) was used as an assessment tool before and after the ten-week
treatment program.
Researchers looked at several hypotheses, but the main hypothesis of
this study was that ACT treatment would result in a reduction of
maladaptive interpersonal functioning as compared to treatment as usual.
This hypothesis was tested via an examination of participants’ pre- and
post-treatment scores on the IIP-64. The table at the end of this appendix
compares pre- and post-treatment test scores for participants in the
treatment versus control group. (As a side note, the IIP-64 demonstrated
excellent internal consistency, with Cronbach’s a = 0.96 at post-treatment,
consistent with prior research.)
A mixed factorial analysis of variance (ANOVA) was performed to
examine whether participants in the treatment versus control group
exhibited differential changes in their IIP-64 scores over time. Overall,
there was a main effect of assessment time, such that participants had lower
IIP-64 scores at the post-treatment assessment (M = 1.20, SD = 0.63) as
compared to the pre-treatment assessment (M = 1.45, SD = 0.66), F(1, 42) =
2
13.074, p < 0.01, η = 0.237. The effect size indicates that assessment time
explained 23.7 percent of the variance in IIP-64 scores. This main effect is
qualified, however, by a significant interaction between experimental group
2
and assessment time, F(1, 42) = 18.35, p < 0.001, η = 0.304, such that
participants in the ACT condition group exhibited a significant decrease in
IIP-64 scores from pre-treatment (M = 1.64, SD = 0.66) to post-treatment
(M = 1.09, SD = 0.62), t(21) = 5.41, p < 0.001, while control group scores
did not change significantly from pre-treatment (M = 1.27, SD = 0.62) to
post-treatment (M = 1.31, SD = 0.64), t(21) = –0.486, p = 0.63, ns.
Participants did not differ significantly on their IIP-64 scores by group, F(1,
42) = 1.84, p = 0.67, ns, indicating that the two samples were matched on
their levels of maladaptive interpersonal functioning prior to treatment. The
effect size of the interaction term indicates that the interaction between
treatment group and assessment explained 30.4 percent of the variance in
IIP-64 scores. This effect size can be considered quite large (J. Cohen,
1988), implying that the ACT treatment resulted in a large and potentially
meaningful reduction of participants’ maladaptive interpersonal
functioning, beyond the reduction in these behaviors in the control group.
An independent samples t-test comparing the pre- and post-treatment
IIP-64 score differences between the two treatment groups supported the
hypothesis that participants in the ACT treatment group (MPost – MPre = –
0.55) would exhibit a greater reduction in maladaptive interpersonal
functioning as compared to those in the control group (MPost – MPre =
0.05), t(42) = –4.28, p < 0.001, d = –1.23. The Cohen’s d represents quite a
large effect size and indicates that the difference between the mean scores
for the treatment group is 1.23 standard deviation units larger than the
difference between the mean scores for the control group.
In sum, the main hypothesis was supported by the data from the IIP-64.
Participants who completed a ten-week ACT treatment exhibited greater
improvement in their interpersonal functioning as compared to participants
in the control group. Given prior research establishing empirical support for
ACT treatment for a wide variety of psychological problems (see Ruiz,
2010), these results are quite promising for the treatment of interpersonal
problems, although caution must be used in the interpretation of these data,
given the small sample size.
 Note: Negative difference scores indicate a reduction in problem
behaviors from pre-treatment to post-treatment.
 Appendix C

Group Protocol (Written with Koke

Saavedra)
This appendix provides a complete protocol for conducting ACT for
interpersonal problems in a group setting over the course of ten ninety-
minute sessions. The ideal group size is eight to ten members. However, the
protocol can easily be adapted to other group sizes and formats. In addition,
you may wish to adjust the amount of time devoted to different elements of
each session, depending on the needs of group members or the focus of the
group.
A similar protocol has been tested and showed good results (see
appendix B), although it must be noted that the sample size in that study
was relatively small. Still, given prior research establishing empirical
support for ACT treatment for a wide variety of psychological problems
(Ruiz, 2010), we feel that this protocol, if conducted with sensitivity and
flexibility, will be beneficial for most clients.
We’ve provided guidance on the amount of time to spend on each
procedure in each session. However, these are only rough guidelines.
Depending on the group, you may need to devote more or less time to
particular procedures. If a session runs long and you can’t fit everything in,
simply cover the remaining elements in the next session. The last two
sessions aren’t as full and therefore provide flexibility at the end of the
protocol.

Session 1
Session 1 begins with a brief mindfulness practice to help group members
begin cultivating this important skill. Most of the session is dedicated to
psychoeducation about the ten schemas with the greatest impact on
interpersonal relationships and associated schema coping behaviors. The
session also includes whiteboard exercises to facilitate group discussion and
exploration of these topics.
 Procedures

1. Administer a pre-treatment assessment (such as the Young Schema Questionnaire;

see appendix A) and any outcome measures you’d like to use.

2. Guide the group in a mindfulness practice (Mindful Focusing or the Five Senses
Exercise; 5 minutes).

3. Provide psychoeducation on schemas (Ten Key Schemas handout; 20 minutes).

4. Conduct a whiteboard exercise exploring why schemas are so powerful (15 to 20

minutes).

5. Provide psychoeducation on typical schema coping behaviors (Ten Common

Schema Coping Behaviors handout and monster at a party metaphor; 20 minutes).

6. Conduct a whiteboard exercise exploring how schemas affect clients emotionally

and cognitively (20 minutes).

7. Assign homework (5 minutes).

1. Administer a Pre-Treatment Assessment

Have clients fill out a schema questionnaire before the session. (We
recommend the Young Schema Questionnaire, which you can purchase at
schematherapy.com; see appendix A for an example.) The schema
questionnaire is used to identify members’ schemas, not as an assessment
measure. The purpose is to identify which schemas are most salient for each
member. Group members can then choose which schemas resonate with
them the most and which they would like to focus on. Also administer any
outcome measures you’d like to use, such as the Valued Living
Questionnaire (VLQ; Wilson, Sandoz, Kitchens, & Roberts, 2010), the
Automatic Thoughts Questionnaire (ATQ; Hollon & Kendall, 1980), the
Acceptance and Action Questionnaire–II (AAQ-II; Bond et al., 2011), or
the Inventory of Interpersonal Problems (IIP-64; Horowitz et al., 2000).

2. Lead a Mindfulness Practice

 Guide the group in a brief mindfulness practice: either Mindful
Focusing or the Five Senses Exercise (see chapter 4).

3. Provide Psychoeducation on Schemas

Give the group members their results from the schema questionnaire
you administered, along with the handout Ten Key Schemas. Have
members circle the three schemas where they scored highest and ask them
whether these schemas seem to correlate with their experience. Then
discuss the concept of schemas and how they arise. Here’s a script showing
how you might do so:

A maladaptive schema is essentially a belief about yourself and your

relationship to the world. It creates a feeling that something is
wrong with you, your relationships, or the world at large. Schemas
are formed in childhood and develop as a result of ongoing
dysfunctional experiences with parents, siblings, and peers during
childhood, and they continue to grow as children try to make sense
of their experience and avoid further pain. Schemas come from
repeated toxic messages that we get about ourselves from our early
experiences, such as “You’re bad” or “You can’t do anything right,”
or from specific traumatic events. Once a schema is formed, it’s
extremely stable and becomes an enduring pattern that is repeated
throughout your life.
Schemas are like sunglasses that distort all of your experiences.
They color the way you see things, and they make assumptions and
predictions that tell you the schema is true or will turn out to be
true. Schemas formed during childhood are triggered repeatedly
throughout your adult life. Common triggers include stressful
interpersonal events and difficult thoughts and feelings. Once a
schema is triggered, it brings up powerful automatic thoughts and
feelings about yourself that can lead to depression, panic,
loneliness, anger, conflict, inadequate work performance, addiction,
and poor decision making. Schemas interfere with the ability to feel
safe in relationships, to get your needs met, and to meet the needs of
others.
 Ten Key Schemas

Psychologist Jeffrey Young has identified eighteen early maladaptive schemas. Ten of
these schemas have significant relevance to interpersonal relationships. A schema is
a core belief. Core beliefs define who we are and direct how we live our lives. They
create the internal monologue that characterizes the thoughts, assumptions, and
interpretations that inform each person’s individual worldview. When a schema is
activated, it produces intense emotions. Identifying your schemas and examining how
they impact your life and your interactions with others is essential to making positive
changes in your relationships. Study this list of the ten schemas relevant to problems
in interpersonal relationships and keep it handy so you can identify which schemas
are affecting your interactions:

Abandonment and instability: the belief that significant people in your life are
unstable or unreliable

Mistrust and abuse: the expectation that you will be harmed through abuse or
neglect

Emotional deprivation: the expectation that your needs for emotional support
won’t be met, which may take several forms:

Deprivation of nurturance: the absence of attention

Deprivation of empathy: the absence of understanding

Deprivation of protection: the absence of guidance

Defectiveness and shame: the belief that you are defective, inferior, or unlovable

Social isolation and alienation: the belief that you don’t belong to a group, are
isolated, or are radically different from others

Dependence and incompetence: the belief that you are incapable or helpless and
require significant assistance from others, that you cannot survive without a certain
person, or both

Failure: the belief that you are inadequate or incompetent and will ultimately fail

Entitlement: the belief that you deserve privileges and are superior to others
 Subjugation: voluntarily meeting the needs of others at the expense of your own
needs, submitting to others to avoid real or perceived consequences, or
surrendering control to others due to real or perceived coercion

Unrelenting standards and hypercriticalness: the belief that you must meet very
high internalized standards to avoid criticism, leading to impairment in areas of life
such as pleasure, health, and satisfying relationships

4. Explore Why Schemas Are So Powerful

Discuss clients’ specific schemas and what makes them so powerful and
hard to change. List ideas from the group on the whiteboard. Possible
reasons include the power of core beliefs, how intractable old habits can be,
that schemas predict the future and therefore help us feel safe, that schemas
are self-perpetuating, that they are experienced as truths about ourselves, or
that they bring up a lot of strong emotions and thoughts.

5. Provide Psychoeducation on Schema Coping Behaviors

Take some time to explain schema coping behaviors (SCBs), perhaps
starting with the metaphor of a popcorn machine to illuminate how thoughts
are generated spontaneously and continuously:

The mind is a popcorn machine, eternally popping up thoughts and

judgments connected to our schemas and pulling us to use old,
habitual ways of responding to the associated pain. When a schema
is triggered, we tend to respond with behaviors that attempt to
control or block the pain connected to the schema. I’ll refer to these
as schema coping behaviors. Once a schema is triggered, we want
desperately to get rid of the thoughts and feelings that come with it,
such as shame, fear, rejection, or hurt. We tend to use one or more of
three broad strategies to attempt to get rid of our schema-related
pain: attack, surrender, and avoidance. Here’s a handout that
outlines ten common schema coping behaviors that tend to be most
damaging to relationships.
 Give group members the handout Ten Common Schema Coping
Behaviors (based on Young et al., 2003). After reviewing these common
coping behaviors, begin to address the costs of these behaviors, along with
the importance of willingness to have difficult private experiences that
come up when engaging in valued actions.

Ten Common Schema Coping Behaviors

Overcompensation
Aggression or hostility: If you use this coping behavior in response to a schema-
triggering event, you’ll find yourself counterattacking by blaming, criticizing,
challenging, or being resistant.

Dominance or excessive self-assertion: If you use this coping behavior in

response to a schema-triggering event, you’ll find yourself trying to control others in
order to accomplish your goals.

Recognition seeking or status seeking: If you use this coping behavior in

response to a schema-triggering event, you’ll find yourself overcompensating by
trying to impress others and get attention through high achievement and status.

Manipulation or exploitation: If you use this coping behavior in response to a

schema-triggering event, you’ll find yourself trying to meet your own needs without
letting others know what you’re doing. This may involve the use of seduction or not
being completely truthful to others.

Passive-aggressiveness or rebellion: If you use this coping behavior in response

to a schema-triggering event, you’ll appear to be compliant but will rebel by
procrastinating, complaining, being tardy, pouting, or performing poorly.

Surrender
Compliance or dependence: If you use this coping behavior in response to a
schema-triggering event, you’ll find yourself relying on others, giving in, being
dependent, behaving passively, avoiding conflict, and trying to please others.
Avoidance
Social withdrawal or excessive autonomy: If you use this coping behavior in
response to a schema-triggering event, you’ll find yourself isolating socially,
disconnecting, and withdrawing from others. You may appear to be excessively
independent and self-reliant, or you may engage in solitary activities such as
reading, watching TV, computer use, or solitary work.

Compulsive stimulation seeking: If you use this coping behavior in response to a

schema-triggering event, you’ll find yourself seeking excitement or distraction
through compulsive shopping, sex, gambling, risk taking, or physical activity.

Addictive self-soothing: If you use this coping behavior in response to a schema-

triggering event, you’ll find yourself seeking excitement with drugs, alcohol, food, or
excessive self-stimulation.

Psychological withdrawal: If you use this coping behavior in response to a

schema-triggering event, you’ll find yourself escaping through dissociation, denial,
fantasy, or other internal forms of withdrawal.

The metaphor of a monster at a party (similar to Joe the Bum in Hayes

et al., 1999) can be useful here. When working with this metaphor, invite
group members to think about their own coping behaviors and share what
they would do at the party if their schema was activated. This metaphor is
intended to be used interactively, not just as a didactic device:

To give an example of how the thoughts and feelings that come with
a schema can cause you to use unhelpful coping strategies, and to
help you understand how your struggle to avoid the pain of a
schema may lead you to behave in a way that actually exacerbates
the schema, think of schemas as loud, obnoxious monsters. Imagine
that you’re throwing a party—the biggest party you’ve ever hosted,
and you’re extremely excited about it. You send out invitations
saying that everyone is invited to the party.
This party is extremely important for you. You want it to be a
huge success. So, not surprisingly, your failure schema shows up at
the party and tells you, “This party is horrible. The guests aren’t
going to enjoy themselves. No one will want to come to any of your
parties again. The food is terrible. The music is terrible. You can’t
get anything right. People look bored.” You try to get rid of your
failure schema. You try to close the door in his face, but he pushes
his way in. You try to wrestle him out the door, but he fights back
and the two of you make a huge commotion. And the more you fight,
the less your guests are enjoying themselves.
You might try to disprove your failure schema by seeking
reassurance and asking everybody at the party if they’re having a
good time, if they’re bored, if they like the music, if they need
anything, if the food is okay. You might try to avoid your failure
schema by withdrawing or keeping busy with trying to make sure
everything is perfect. You might buy into your failure schema’s ideas
that people are having a bad time and behave in a defensive or
attacking way, saying things to your guests like “You never enjoy my
parties. You never dance at any of my parties. You always complain
about my cooking. I wouldn’t do this at one of your parties.” You
might decide to surrender completely, isolating yourself in your
bedroom and giving up on the whole party.
You wanted to have a good time at the party, but you’re so
preoccupied with avoiding your schema and trying to get rid of him
that you haven’t been able to enjoy yourself. But what if this
schema-related pain is unavoidable? What if it will always show up
under certain circumstances? What if every time you try to do
something that’s important to you, like pull your life together, go to a
job interview, have a loving relationship, or throw a fantastic party,
this pain is going to show up? Could you be willing to allow your
schema of failure, defectiveness, abandonment, or whatever to
simply be there as you do something you value, like being present
for and enjoying your party? Could you be willing to have all of the
feelings and thoughts that come with your schema and still be
engaged and present at the party without struggling against it?
Would you be willing to learn to relate to your schema in a different
way—maybe invite him in, keep some distance from him, observe
him, and know that you can choose whether or not to let him impact
your behavior? Can you recall a time when schema thoughts and
feelings tried to stop you from doing something important, but you
did it anyway?
6. Explore How Schemas Affect Clients Emotionally and Cognitively
Guide the group in exploring how schemas affect them emotionally and
cognitively. What emotions and thoughts typically accompany each
schema? List the ten key schemas on the whiteboard and have group
members identify thoughts and feelings that come up when particular
schemas are activated. List the relevant emotions and thoughts next to each
schema. Using the handout Ten Common Schema Coping Behaviors, have
group members identify the schema coping strategies they most often use to
avoid their schema-related pain. Explore the outcome of using a particular
schema coping behavior when a schema is triggered.

7. Assign Homework
Educate group members about the importance of following through with
homework assignments and explain that homework is a core mechanism for
promoting change and making progress in therapy. Homework provides
clients with an opportunity to practice new skills in their relationships and
explore workability. Then assign the following homework to group
members to be practiced throughout the week:

Ask clients to notice when schemas are triggered and identify which
schema has been activated. Have them observe what happened to
trigger the schema and note any reactions or urges to react.

Do at least three minutes of Mindful Focusing every day.

Session 2
Session 2 also begins with a brief mindfulness practice to help group
members continue cultivating this skill. The focus of this session is on
cultivating creative hopelessness (Hayes et al., 1999). This is accomplished
by examining group members’ typical schema coping behaviors and
assessing their costs and effectiveness. In addition, by exploring their
schema triggers and schema-related thoughts, feelings, and coping
behaviors, clients are also developing more awareness of signals that can
alert them to when their schemas have been triggered, which can eventually
lead to responding to these events more mindfully.
 Procedures

1. Guide the group in a mindfulness practice (Mindful Focusing or the Five Senses
Exercise; 5 minutes).

2. Review group members’ experiences with the homework from session 1 (15 to 20
minutes).

3. Explore schema triggers, coping behaviors, and outcomes through a whiteboard

exercise (Schema Triggers, Thoughts, Feelings, and Coping Behaviors Worksheet;
40 minutes).

4. Conduct a whiteboard exercise exploring creative hopelessness (20 minutes).

5. Assign homework (5 minutes).

1. Lead a Mindfulness Practice

Guide the group in a brief mindfulness practice: either Mindful
Focusing or the Five Senses Exercise (see chapter 4).

2. Review Homework
Ask group members to share what they noticed when their schemas
were triggered over the past week.

3. Explore Schema Triggers, Coping Behaviors, and Outcomes

Briefly review what schema coping behaviors are, then explain how
they arise:

As we talked about in the previous session, schema coping

behaviors are responses aimed at blocking or controlling schema-
related pain. These coping behaviors may offer temporary relief in
the moment, but in the long run they contribute to the schema, make
 it feel more true, and actually increase schema-related emotional
pain.
You may wonder where these unhelpful behaviors come from. We
learn them by watching our parents and other family members deal
with pain. Dad may have gotten angry and gone on the attack when
he was hurt. Mom may have collapsed and given up. A sister may
have withdrawn in her bedroom. A brother may have started to
drink.
In addition, sometimes we come up with schema coping
behaviors on our own. When a schema is triggered, we may stumble
upon a way of responding that feels like it offers some relief from the
emotional pain. Because it seems to work, at least temporarily, we
stick with it, doing the same thing again and again in similar
situations.
The trouble with schema coping behaviors is that they tend to
hurt other people, relationships, and, ultimately, the person who’s
using them. Our relationships stop feeling good to the people who
are important to us. After a while they may give up on us or harden
and withdraw. So, although schema coping behaviors may offer
some temporary relief, in the long run they make us feel worse about
ourselves—and may cause us to lose people we love.

Introduce the six domains of interpersonal relationships: work, friends,

family, intimate relationships, parenting, and community. Then hand out the
Schema Triggers, Thoughts, Feelings, and Coping Behaviors Worksheet.
Ask group members to think of the schema that most affects them and
then write it at the top of the worksheet. Alternatively, you can have them
write down different schemas for various domains. For example in the work
domain, a failure schema may be most relevant, and for intimate
relationships, abandonment may be a bigger issue. Next, ask them to
consider what triggers the schema in each relevant domain of relationships.
Spend a few minutes discussing such triggers as criticism, anger,
withdrawal, and demands from others, and feeling close, vulnerable, or
jealous. Work with one group member to list his or her triggers in each
relevant domain on the whiteboard and have the other group members list
their own triggers on their worksheets as you do so.
 Have group members recall incidents when their schemas were
triggered, then ask them to try to identify thoughts and feelings that tend to
be connected with particular schemas. Help them get very specific and
come up with as many thoughts and feelings as they can, then have them
list those thoughts and feelings on the worksheet.
Next, explore schema coping behaviors with a few questions:

When your schema gets triggered, what do you do? For example, if
you have a defectiveness schema, how do you cope when you get
criticized? What do you do to deal with the shame or hurt?

Again, work with one group member and list his or her coping
behaviors on the whiteboard and have the other group members list their
own schema coping behaviors on their worksheets as you do so. Discuss
what happens when they use an SCB and how this is working for them. Get
specific by exploring the outcomes of one group member’s schema coping
behaviors in a particular relationship. Long-term, did the relationship get
better or worse? Long-term, did the client feel better or worse? Explore
schema maintenance and the way the coping behaviors maintain, contribute
to, and exacerbate the schema-related pain. For example, you might point
out that the more we attempt to avoid being abandoned by using such
coping behaviors as getting suspicious, accusing, and blaming, the more
likely we are to actually get abandoned, which maintains the abandonment
schema.

4. Explore Creative Hopelessness

Use the coping behaviors group members identified on the Schema
Triggers, Thoughts, Feelings, and Coping Behaviors Worksheet to begin
working with creative hopelessness. This key ACT strategy is very effective
but also challenging, so provide motivation by exploring how effective old
strategies have been in reducing schema-related pain in the long run:

Let’s write down all of the behaviors that you’ve tried in an effort to
get rid of the painful feelings that come with schemas. Since many of
you have identified a failure schema, let’s use that for this exercise.
What strategies have you used to try to avoid feelings of
defectiveness, fear, hopelessness, lack of self-worth, inadequacy,
anxiety, and so on?

As you list strategies on the whiteboard, explore whether any of these

techniques have been successful in permanently eliminating the pain.
Continue exploring this and writing down avoidant behaviors to get to the
underlying control strategies that group members have used to avoid
schema-related pain:

So here are all of these strategies that you’ve been using to avoid
this deep pain. But what I’m hearing is that none of them have
actually worked to get rid of it in the long run. You might feel a little
relief in the moment, but over time, the pain gets worse. You’ve put
in so much effort, and for so long, but that pain still comes back.
You’ve tried so many different strategies to avoid this pain, and yet
the problem still remains. The struggle is still there; the pain still
shows up.
 What if this pain is unavoidable? What if this schema-related
pain is never going to go away? What if it’s in you? Maybe the
answer isn’t getting rid of this pain. What if the answer lies in the
pain itself? What if this familiar pain is going to have a tendency to
show up whenever you take a step toward something meaningful in
your relationships? Maybe the answer lies in relating to this pain in
a different way: observing your schema, being curious about it, and
being willing to have it come up when you’re about to do something
important and meaningful.
What do we have control over? What can we change? Can we
change our schemas and the thoughts and feelings that come up
when they’re activated? Can we change our schema coping
behaviors?

5. Assign Homework
Assign the following homework to be practiced throughout the week:

Ask clients to watch for moments when schemas are triggered,

notice coping behaviors, and assess their outcomes.

They should do at least ten minutes of Mindful Focusing every day.

Session 3
As in sessions 1 and 2, begin with a brief mindfulness exercise. This session
continues the work of exploring the outcomes of old coping behaviors to
establish that they aren’t helpful in the long run. This work helps group
members arrive at creative hopelessness, which must occur before
proceeding further with therapy, as it sets the stage for trying something
new.

Procedures
 1. Guide the group in a mindfulness practice (Mindful Focusing or the Five Senses
Exercise; 5 minutes).

2. Review group members’ experiences with the homework from session 2 (15 to 20
minutes).

3. Explore the costs of schema coping behaviors through a whiteboard exercise

(Schema Coping Behavior Outcomes Worksheet; 30 minutes).

4. Discuss creative hopelessness and use such metaphors as quicksand and digging
a hole to help group members grasp this key concept (20 minutes).

5. Help group members stop the struggle for control using a visualization based on a
metaphor of the sky and the weather (10 minutes).

6. Assign homework (5 minutes).

1. Lead a Mindfulness Practice

Guide the group in a brief mindfulness practice: either Mindful
Focusing or the Five Senses Exercise (see chapter 4).

2. Review Homework
Ask group members to share moments over the past week when their
schemas were triggered and to describe how they reacted.
3. Explore the Costs of Schema Coping Behaviors
Hand out the Schema Coping Behavior Outcomes Worksheet and ask
group members to fill in what happens in each relevant domain when they
use their typical coping behaviors, with a focus on the main outcomes.
Explain that the outcome of a coping behavior is the effect it has on a
particular relationship and the other person in that relationship. Ask clients
to consider how the relationship changes as a result of using that coping
behavior.
Work with one group member to list his or her outcomes on the
whiteboard and have the other group members fill out their own worksheets
as you do so. Maintain a running inquiry with the group member you’re
working with directly, asking about his or her sense of whether each
outcome was positive or negative. This discussion can help group members
see how maladaptive coping behaviors often exacerbate schemas, schema-
related feelings, and, ultimately, interpersonal problems.
4. Discuss Creative Hopelessness
Understanding the costs of maladaptive behaviors sets the stage for
creative hopelessness—a painful but pivotal point where group members
discover new solutions and commit to new, values-based behaviors. Begin
by asking the group to acknowledge the costs. After they’ve responded,
introduce the term “creative hopelessness” and suggest that the solution lies
in accepting and facing their pain:

Most of your efforts with these old ways of coping with schemas
seem to result in more pain—for you and the people you love. Is this
true?
Creative hopelessness is the realization that everything you’ve
done to control and to minimize schema-related pain hasn’t worked,
and that, if anything, these efforts have made the pain worse. Now
that you know your old coping behaviors have created more pain,
you can think about alternative solutions. If running from and
avoiding schema-related pain hasn’t worked, perhaps the answer is
to stop running. Perhaps the answer lies in the pain itself. What if
facing and accepting the fear, shame, or hurt connected to your
schemas is the answer?

Group members may remain attached to avoidance as a strategy or have

difficulty accepting the basic premise that avoidance only leads to more
pain. You might try to explain this dynamic didactically:

The problem with struggling with our thoughts and feelings is that
the more we struggle, the stronger these thoughts and feelings
become. The more we try to avoid pain, the stronger the pain
becomes.

Metaphors can be useful here. Use the quicksand metaphor (Hayes &
Smith, 2005) and possibly also the metaphor of digging a hole (Hayes et al.,
1999), both described in chapter 4, to illustrate the concept. After
presenting the metaphors, explore group members’ thoughts as follows and
list their responses on the whiteboard:
 What are the costs of struggling in quicksand and trying to make
painful thoughts and feelings go away? What are the interpersonal
and emotional costs?

5. Help Group Members Stop the Struggle for Control

The simple yet profound metaphor of how the sky holds the weather
(Harris, 2009) can help group members see that painful experiences are
transitory, which can help them let go of the struggle to control their
experience. It can also open the door to developing the observer-self
perspective. Here’s a script for a visualization based on the metaphor of the
sky and the weather:

So, if struggling and trying to control your thoughts, feelings, and

internal experiences doesn’t work, what can you do? I’d like to
guide you in a visualization that will help you see how you can
relate to them differently. If you’re willing, close your eyes, then pay
close attention to your breath, feeling the air going in and out of
your nostrils. Feel your feet on the floor. Get in touch with where
you are right now, in this moment.
Now imagine that you are the sky. The sky is always there,
holding the constantly changing weather. The weather is sometimes
cloudy and dark, sometimes snowy, sometimes rainy, and sometimes
sunny, with a gentle breeze and fluffy white clouds. As wind, storms,
rain, and sunshine come and go, the sky is always there, just
receiving each change of weather with perfect willingness. The sky
isn’t invested in what the weather should be. Difficult thoughts and
emotions also come and go, just like sunny and cloudy days.
Having different weather is necessary in life. You wouldn’t take
the same delight in a beautiful sunny day if every day was bright
and blue. We need rain to supply water. Similarly, we need our pain
to let us know when we’re off track or have lost sight of what’s
important.
Do you think you could just observe and have all of your
weather, without trying to change or struggle with it? Could you
simply observe the sensations in your body, the thoughts going
 through your head, and your emotions? Sometimes you’re sad, and
sometimes you’re happy. Sometimes you’re insecure, and sometimes
you’re confident. Would you be willing to just notice all of your
experiences as they unfold, moment by moment?
Being the sky is like being an observer of your experience. The
observer self is clear and boundless and always willing to simply
hold passing experiences, just like the sky. The observer self is a
place from which you can have all of your experiences without
resisting or wrestling with them. It’s also a place from which you
can choose actions that are consistent with the kind of person you
want to be in your relationships.
To the observer self, thoughts and emotions are like the weather,
ever passing, ever changing. Difficult thoughts and emotions,
including those triggered by your schemas, are like terrible, scary
storms with thunder, lightning, and howling wind. Eventually, the
storm quiets and the air clears. There are storms in the sky. That’s
unavoidable; it’s just part of the weather. When we learn to stop
struggling with our weather and instead simply observe it mindfully,
we can begin to notice that painful thoughts and emotions come and
go, just like the weather in the sky.

6. Assign Homework
Assign the following homework to be practiced throughout the week:

Ask group members to watch for their two most powerful schemas
throughout the next week, watching for them in conversations and
other interactions. Remind them that painful emotions, such as
anger, sadness, or shame, can serve as red flags that their schemas
have been activated. As they watch their experience, have them
notice the moment when they’re tempted to use old coping
behaviors. Identify this as “the moment of choice”: the point where
they have the option to do something different, even if they aren’t
yet able to do so.

Have them do at least ten minutes of Mindful Focusing every day.

 Session 4
Once again, begin with a brief mindfulness exercise to help group members
continue to develop this skill. In this session, the focus turns to values.
Various worksheets and exercises are employed to help group members
clarify their values, develop values-based intentions, and identify barriers to
valued action. A role play based on the metaphor of monsters on the bus
(Hayes & Smith, 2005) is used to help group members find new ways of
relating to perceived barriers.

Procedures

1. Guide the group in a mindfulness practice (Mindful Focusing or the Five Senses
Exercise; 5 minutes).

2. Review group members’ experiences with the homework from session 3 (10
minutes).

3. Provide psychoeducation on values (10 to 15 minutes).

4. Assist group members in clarifying values and identifying valued intentions (Valued
Intentions Worksheet; 25 to 30 minutes).

5. Explore obstacles to valued action (Assessing Barriers Worksheet; 15 to 20

minutes).

6. Conduct a role-playing experiential exercise based on the monsters on the bus

metaphor (10 to 15 minutes).

7. Assign homework (5 minutes).

1. Lead a Mindfulness Practice

Guide the group in a brief mindfulness practice: either Mindful
Focusing or the Five Senses Exercise (see chapter 4).

2. Review Homework
 Ask group members to share their experience in watching for the
moment of choice. Ask whether they were able to notice when their
schemas were activated and any associated urges to engage in old coping
behaviors. Also ask whether they were able to identify this as the moment
of choice.

3. Provide Psychoeducation on Values

Before beginning the work of clarifying values and identifying values-
based intentions, explain values from the ACT perspective. Be sure to
address that values are freely chosen and personal and to establish the
distinction between values and goals. Here’s a sample script (based on
Vuille, 2006b):

As we’ve discussed in previous sessions, problematic old coping

behaviors are having a big impact on your relationships. But it
doesn’t have to be that way. There are ways you’d rather be and
rather act—ways based on deep values—that could make your
relationships feel much better. Choosing the direction you want to
go in your life is similar to being the director of the movie of your
life, except that you have limited control. You can only control the
actor who’s playing your role in the movie. You can choose how that
actor responds, behaves, talks, and acts, but you can’t control any of
the other actors or the events taking place in the movie. But you can
have the actor playing your role behave exactly like the person you
want to be—your own ideal version of yourself.
How would you want this actor to relate to others and behave in
relationships? What this boils down to is what you want to stand for.
This is where you’ll find your deepest, most meaningful values. As
you start thinking about your values, there are a couple of things to
keep in mind. The first is that values are personal and must be
authentic. Think about what really matters to you, not what you
think “should” matter, and not what you think other people believe
you should value.
The second thing is that values are different from goals. Values
are like a direction you want to travel in, whereas goals are specific
 steps along the way. A value reflects how you want to be. A goal, or
intention, is a specific action you can take in the service of that
value.

4. Clarify Values and Identify Valued Intentions

Next, hand out the Valued Intentions Worksheet, then introduce the six
interpersonal domains. To help group members identify their core values,
you might ask them to think about their own funeral or epitaph and how
they’d like to be remembered (Hayes et al., 1999):

In today’s session, we’re going to explore your core values. To learn

more about how you want to be in your relationships, we’ll look at
six domains of relationships: work relationships, friendships, family
relationships, partner relationships, parenting, and community
relationships. For each domain that’s relevant to you, identify at
least one core value about how you’d like to be—how you’d like to
interact with others in those relationships. Imagine that you are at
your own funeral; imagine you are hearing your own eulogy. What
would you like people to say about you? What kind of person would
you like to be? How would you want to be remembered?
 Working with one group member at the whiteboard to exemplify the
process, ask group members to assign a rating of importance to each
domain using a scale of 0 to 2, where 0 means not important, 1 means
moderately important, and 2 means very important. Next, ask them to select
one of the domains with the highest rating to work on in this session. Then
have them identify one or two key values in regard to relationships in that
domain. Explain that the group will continue to work on values in all
remaining sessions, so they’ll have a chance to work on other domains in
upcoming sessions.
The next step is to convert these general values into specific behavioral
intentions, which are essentially goals, as described above. For example,
how, exactly, would a group member turn the parenting value “giving my
children the experience of being loved” into action? Specific intentions
might include “Spend ten minutes on Thursday night reading to them” or
“Spend ten minutes Thursday night asking them how their day went or how
their friends are doing.” Generating specific intentions allows group
members to develop a targeted plan for behavioral change based on their
values. Explain that the group will also continue to work on valued
intentions in all remaining sessions, that you’ll ask them to identify and
commit to one intention each week from this point forward, and that
therefore they need not begin with something highly challenging.
If time allows, you can have the group clarify values and identify valued
intentions in several domains. If group members have listed several
intentions, ask them to rate the importance of their each intention on a scale
from 1 to 10, where 1 means it hardly matters and 10 means it’s of the
greatest importance. Before moving on, ask group members to select an
intention that they are willing to commit to acting on over the next week.

5. Explore Obstacles to Valued Action

Next, ask group members to envision acting on this intention. Hand out
the Assessing Barriers Worksheet. Work with one group member at the
whiteboard and ask the rest of the group to fill out the worksheet, listing
potential barriers to acting on the intention they’ve committed to. What
emotions or thoughts might get in the way?

6. Role-Play the Monsters on the Bus Metaphor

As discussed in chapter 5, the monsters on the bus metaphor (Hayes &
Smith, 2005) is an excellent way to help clients work with barriers. In group
therapy, you can have the group role-play the metaphor. Have each member
focus on the intention they committed to for the week and on the barriers
that show up for them regarding this intention. Ask one group member
whether he or she would be willing to come up to do an experiential role
play, or ask for a volunteer. Begin to describe the metaphor to this client,
along these lines:
 Imagine that you’re a bus driver, and that the bus is your life. You
want to steer toward your values and the things that are important
to you, but there monsters that try to stop or divert you. These
monsters are your barriers. They know your deepest insecurities and
know exactly what to say to stop you from going in the direction you
want to go.

Ask six other group members whether they’d be willing to come

forward and participate. Assign each of the six a specific thought, feeling,
or memory from the first member’s list of barriers, then have them role-play
the monsters while the first client attempts to drive toward her or his value.
Have these seven group members act out the scenario, with the first
member trying to go toward a specific intention as the monsters keep
showing up in front of the bus. Ask the driver what he or she would like to
do about the monsters. Drivers will probably try a number of different
strategies, such as trying to run over the monsters, bargaining with them,
and threatening them. As the role play continues, help the driver see that
these strategies aren’t working and haven’t been working. Ask the driver
what he or she might do differently. If the driver doesn’t come up with the
option of letting the monsters onto the bus, ask the group for suggestions.
Typically, a group member will eventually come up with this option. If no
one in the group suggests the option of bringing the monsters onto the bus,
eventually suggest this as an option that allows for more freedom to travel
in valued directions.

7. Assign Homework
Assign the following homework to be practiced throughout the week:

Ask group members to commit to following through on one

intention throughout the next week. When schemas are activated
and present barriers to acting on that intention, notice the moment of
choice and persist in the valued behavior anyway.

Have them do at least ten minutes of Mindful Focusing every day.

Session 5
Again, begin with a brief mindfulness exercise to help group members
continue to develop this skill. In this session, the focus turns to cognitive
defusion. Metaphors are used to illustrate how schema-related thoughts can
serve as barriers to values-based action and how the mind is continuously
generating thoughts. The rest of the session is devoted to explaining
specific defusion techniques and practicing a few of them in session.
Several of these techniques may also be helpful with emotions and other
private experiences.

Procedures

1. Guide the group in a mindfulness practice (Mindful Focusing or the Five Senses
Exercise; 5 minutes).
 2. Review group members’ experiences with the homework from session 4 and set a
new intention for the coming week (Valued Intentions Worksheet; 15 to 20 minutes).

3. Provide psychoeducation on defusion (monsters on the bus and sales

representative metaphors and Assessing Barriers Worksheet; 10 to 15 minutes).

4. Teach specific defusion techniques (Defusion Skills handout; 10 to 15 minutes).

5. Have group members practice defusion techniques in session (visualization of

putting thoughts on clouds, objectifying, and role-playing a group member’s mind
and schema thoughts; 25 minutes).

6. Assign homework (5 to 15 minutes).

1. Lead a Mindfulness Practice

Guide the group in a brief mindfulness practice: either Mindful
Focusing or the Five Senses Exercise (see chapter 4).

2. Review Homework
Ask group members to share their experience in following through on
their valued intention. Ask whether they were able to notice the moment of
choice. Explore any barriers that came up and brainstorm strategies to deal
with those barriers, then have them set a new intention for the following
week. For those who didn’t follow through, it’s best to continue working on
the previously identified intention unless they have determined that the
intention doesn’t genuinely reflect their values.

3. Provide Psychoeducation on Defusion

Begin by explaining that this session will continue the work of
exploring values. Remind the group that thoughts and feelings can function
as barriers to valued action and that in order to change how they interact
with others, they may need to learn to relate to their internal experiences
differently. Use the monsters on the bus metaphor to explore the idea of
relating to thoughts differently. The sales representative metaphor from
chapter 6 (Vuille, 2006a) can also be helpful. Here’s an example of how you
can weave these two metaphors together to set the stage for defusion:
 Let’s revisit that metaphor of monsters on the bus, from the end of
the previous session. What do you do when you’re driving your bus
in a certain direction and those monsters pop up and try to stop you
or make you turn around? How can you relate to these monsters in a
way that keeps you in control of the direction you’re traveling? The
human mind has a tendency to be full of these monsters, and some of
them are thoughts that keep popping up and trying to stop us from
going toward our destination. If you buy into these thoughts, they
can become real barriers. But you can also notice that they aren’t
real monsters—that they’re just part of the same old schema
thoughts that the mind seems to be so fond of producing.
In a way, these thoughts are like sales representatives. They push
their way in and try to sell you a bunch of products that you really
don’t want. Some of these thoughts are persistent and relentless, and
if you buy one product, they’ll continue throwing more and more
products at you. Some products aren’t very enticing and are easier
to resist, but those schema-driven thoughts seem so true that it’s
hard not to buy into them.
So how can you relate to these sales representatives differently?
Instead of buying the thoughts they offer or trying to explain why
you don’t want to buy them, you can let those pushy sales
representatives into your house, look at what they’re offering, and
then say, “Thank you for all of these products that you’re offering to
sell me, but I’m not interested in buying any of them.”
Look at your Assessing Barriers Worksheet. Which of the
schema-related thoughts that you listed are really good sales
representatives? Which of these thoughts do you buy often? Let’s
practice noticing what they’re trying to sell you, like “I’m never
going to hold a job,” “If people really knew me, they wouldn’t like
me,” “People just use me,” or “I’m going to mess everything up.”
Then thank the sales representative for the offer and say you aren’t
interested in buying that product.

Take some time to establish that the mind tends to generate thoughts
near constantly and that we have very little control over their frequency or
content. The metaphor of the popcorn machine, first introduced in session
1, can be helpful here:

Notice that many of the random thoughts your mind throws at you
aren’t very helpful. Like those monsters, they block your path. They
keep you stuck by pulling you to use old coping strategies that are
ineffective or even damaging. Like we discussed before, the mind
can be like a popcorn machine. It’s constantly throwing thoughts at
you, whether you like it or not. Stories, evaluations, reasons, and
judgments keep coming, and you can’t stop them, can you? So who’s
in charge, you or your mind? Can you stop your mind from popping
thoughts? Can you choose the thoughts your mind pops?
Thoughts include explanations for what’s going on, old stories
about why things happened, and problem solving to try to figure out
how to eliminate pain. They also include judgment—lots and lots of
judgment. Notice that many of the reasons and explanations that
your mind throws at you are just stories that tell you your schemas
are true and give you rules about how you can avoid schema-related
pain. So how can you relate to your mind differently? How can you
gain some distance from the thoughts that keep popping in your
head? How can you free yourself from schema-related thoughts?
The answer lies in practicing observing your thoughts, as well as
your feelings, sensations, and urges, from a distance—disentangling
from them and simply having them, like the sky has the weather.
Then you can notice them without struggling with them, which will
increase your ability to notice those moments of choice when you
have the option to behave differently.

4. Teach Specific Defusion Techniques

Give group members the Defusion Skills handout and briefly explain
defusion:

This handout lists things that you can do to help you observe your
thoughts from a little distance without getting hooked into them or
buying them, so that you can be in control of your destination and
 the direction you’re steering your bus. These techniques are called
defusion skills. “Defusion” may seem like an odd word, and it is
unusual. What it’s getting at is that these skills help you become less
fused or entangled with particular thoughts.

Briefly describe each technique using the handout and provide

instruction in several of them. If you’re unfamiliar with any of these
techniques or would like more details, consult chapter 6, which discusses
many of them. (Also note that chapter 6 includes an alternative Defusion
Skills handout, which lists more skills and doesn’t provide descriptions of
them. You can use whichever version you prefer.)

Defusion Skills

1. Naming the mind. Give your mind a name (other than your own name, of course!).

2. Scheduling a time to worry, obsess, ruminate, get angry, blame, and so on. An
example would be “I’ll put this aside for now and worry about what a failure I am at
eight o’clock tonight.”

3. Assigning descriptive labels to whatever passes through your mind. As you

observe your experience, you can simply acknowledge and label your internal
experience with broad terms like “thought,” “memory,” “desire,” “feeling,” “urge,”
“regret,” “yearning,” “image,” “impulse,” “wish,” “plan,” and “idea.”

4. Having (not being) your experiences. You can use the phrase “I’m having…” to
help you separate yourself from your experiences; for example, “I’m having the
thought that…” “I’m having the evaluation that…” “I’m having the sensation that…”
“I’m having the feeling that…” “I’m having a thought that is predicting…”

5. Labeling thoughts. When you notice specific thoughts, labeling them can help you
let them go; for example, “That was a ‘harsh’ thought,” “That was a ‘judgmental’
thought,” That was a ‘prediction’ thought,” “That was a ‘fear’ thought,” or “That was
a ‘self-hating’ thought.”

6. Thanking your mind. Sometimes the mind will quiet down a bit if it feels it’s been
heard. Try thanking your mind for its sometimes not-so-helpful efforts to help you:
“Thank you, Mind, for that thought [judgment, prediction, memory, or whatever].”
 You can even use the name you’ve come up with for your mind or say you aren’t
interested at this time: “Thank you, Amanda, for that thought, but I don’t want to buy
it right now.”

7. Repeating the thought out loud in a silly voice. You can also sing thoughts.

8. Putting thoughts on clouds. You can visualize putting your thoughts on clouds
and then watching them drift away. Or you may prefer a different image, such as
boxcars on a train passing by, balloons floating away in the sky, or leaves being
carried away on a stream.

9. Objectifying, or thinking of thoughts as physical objects. Imagine what

physical characteristics your thought might have—size, color, texture, shape,
density, consistency, weight, flexibility, temperature, and so on. This technique is
also very useful for disentangling yourself from emotions and other internal
experiences.

10. Physically letting go. As thoughts arrive, rotate your hand so your palm is facing
down and imagine the thought dropping out of sight.

11. Card carrying. In this defusion technique, you carry a card with you and write
down thought monsters as they come up. Then, whenever these painful cognitions
recur, you can remind yourself, “It’s on the card,” and let it go.

5. Practice Defusion in Session

After reviewing all of the techniques, practice a few of them in session.
Putting thoughts on clouds works well as a visualization and is a good place
to begin. Here’s a script for guiding the group in this visualization (Hayes,
Strosahl, and Wilson, 1999):

Close your eyes and imagine that clouds in the sky are drifting past
in front of you, one after another. You’re simply sitting and watching
the clouds floating by. Notice that this takes no effort on your part.
Your awareness, in which these clouds are floating, is very simple
and effortless.
Now look at the thoughts arising in your mind. You might notice
various images, concepts, desires, hopes, fears, and more, all
spontaneously arising in your awareness. They rise up, linger a bit,
and pass. All you need to do, if you are willing, is let your mind
 think whatever thoughts it is already thinking and then put each
thought or image on a cloud and watch it drift away. Simply observe
as your thoughts drift by, one after another. If you don’t like the
image of clouds, you can think of boxcars on a passing train,
balloons floating into the sky, or leaves being carried away by a
stream. Whatever image you use, put your thoughts, memories,
evaluations, judgments, and predictions on them and just watch
them flow away, one after another.
You can see the clouds float by because you are not those
clouds; you are the witness of those clouds. You can feel bodily
feelings because you are not those feelings; you are the witness of
those feelings. You can see thoughts float by because you are not
those thoughts; you are the witness of those thoughts. Once you
notice that your mind has tricked you and you’ve gotten caught up
in thoughts rather than putting them on clouds, congratulate
yourself for noticing that, then just continue putting your thoughts
on the clouds and watching them flow past, one after another. If you
find yourself thinking, “This isn’t working,” “This is weird,” or
“I’m not doing this right,” just put that thought on a cloud too and
watch it float past.

Objectifying, or assigning physical qualities to thoughts (or emotions or

any other internal experiences), lends itself to an in-session exercise. Start
by asking one group member to focus on a typical schema-driven feeling.
Then ask him or her to imagine what physical characteristics this thought
would have if it were an object within the body. Ask about size, color,
texture, shape, density, consistency, weight, flexibility, temperature, and so
on. Then say that you’re going to take the object out of the person. Act this
out and put the imaginary object in front of the group member and ask him
or her for any reactions to having this object standing in front of him or her.
Then objectify this reaction in the same way.
Once the group is familiar with the various defusion techniques, you
can use a role-playing exercise to have them practice choosing defusion
techniques to use in the moment. Ask a group member to list about six
typical schema-driven thoughts and give them to you. Then play the role of
that person’s mind, throwing those thoughts at the person randomly. Have
the person choose defusion techniques from the handout in response to the
thoughts. If the client gets stuck, ask other group members to make
suggestions. Here’s a dialogue showing how this might play out. In this
example, the client has given her mind the name Amanda:
Therapist: Don’t share your feelings with your boyfriend. If he really knew
you he would leave you.
Client: Thank you, Amanda, for that thought.
Therapist: He doesn’t get it. You don’t need him; just keep your distance
and he won’t be able to hurt you.
Client: I’m just going to notice that thought and put it on a cloud.
Therapist: He’s going to leave you and you’re never going to find anyone
better than him.
Client: I’m having the thought that I’ll never find a better boyfriend than
Bill.
Therapist: You need to think about how to keep him from leaving you. Call
him and demand that he explain himself. If you don’t think about
this and figure it out, you’ll end up alone.
Client: Thank you, Amanda, for that thought. I’ll schedule a time to come
back to it. I’ll think about it tonight at eight o’clock.
Therapist: If you don’t think about this right now, you’re just going to
continue to get abandoned.
Client: I’m having the sensation of my heart beating really fast and the
feeling of anxiety.
After demonstrating this approach in front of the group, have group
members get into pairs to continue practicing the exercise. In each pair, one
client acts as the mind, reading from the other’s list of cognitive barriers on
the Assessing Barriers Worksheet, and the second client practices
responding with various defusion techniques. After about five minutes,
have them switch roles. Afterward, reconvene the group and have everyone
explore their reactions to the exercise.
6. Assign Homework
Assign the following homework to be practiced throughout the week:

Ask group members to commit to following through on the valued

intention identified at the beginning of the session and to using
cognitive defusion techniques from the handout while engaging in
committed actions.

Ask that they do at least ten minutes of Mindful Focusing every day.

Encourage group members to notice a thought that’s a pushy sales

representative. What are the consequences of believing this thought?
What are the consequences of not believing it? What are the pros
and cons of believing this thought?

Session 6
At this point, halfway through the ten-week protocol, group members have
probably made significant strides in mindfulness. Therefore, sessions 6
through 9 begin with a review of homework (following through on
committed actions) and setting a new intention for the coming week.
Session 6 focuses primarily on defusion, and specifically on evaluations and
negative self-labels. The session concludes with a visualization to help
group members begin to cultivate the observer-self perspective.

Procedures

1. Review group members’ experiences with the homework from session 5 and set a
new intention for the coming week (Valued Intentions Worksheet; 15 to 20 minutes).

2. Provide psychoeducation on defusion, with a focus on evaluations versus

descriptions (evaluations as prison bars and describing versus evaluating a chair;
10 to 15 minutes).

3. Conduct an experiential exercise in evaluations versus descriptions (telling a story

and noting evaluations; 15 minutes).
 4. Explore self-evaluations via discussion and a whiteboard exercise (self-evaluations
being mood dependent; 20 to 25 minutes).

5. Cultivate self-as-context with an experiential exercise and a visualization

(chessboard metaphor and worst self visualization; 15 minutes).

6. Assign homework (5 minutes).

1. Review Homework
Ask group members to share their experience in following through on
their valued intention. Explore any barriers that came up and brainstorm
strategies to deal with those barriers, then have them set a new intention for
the following week. For those who didn’t follow through, it’s best to
continue working on the previously identified intention unless they have
determined that the intention doesn’t genuinely reflect their values.

2. Provide Psychoeducation on Evaluations vs. Descriptions

Helping group members defuse from old stories and labels about
themselves is essential to helping them get some distance from their
schemas. You can start by assisting them in distinguishing between facts,
which exist in the world and can be tested, versus evaluations, which are in
us and are based on our subjective reality.
Here’s a script (based on Ciarrochi & Bailey, 2008, and Hayes et al.,
1999) for helping explain the distinction between evaluations and
descriptions. You’ll need to modify the description of the chair to match a
chair in the room that you use for the purposes of this discussion:

We’ve been exploring your values and looking at some of the

thoughts and feelings that trigger your schemas, as well as some of
the thoughts and feelings that act as barriers and stop you from
acting on your values. A particularly problematic type of thoughts is
evaluations. They can seem so powerful, and even though they’re
just opinions, they tend to feel real and true—so much so that they
can be like prison bars. But like all other types of thoughts, they are
just products of the mind that come and go. We can choose to buy
into them and let them hold us back, or we can choose not to buy
into them so we can take steps in the directions we want to go. As
with the monsters on the bus, we can bring those thoughts with us to
our destination. Thoughts, feelings, predictions, and evaluations
connected to our schemas aren’t real. They don’t exist in the external
world; they are inside of us. But when you try to take steps toward
doing something that’s important to you, they have a tendency to
come up and seem very real, and that can stop you in your tracks.
Distinguishing between an evaluation and a description is
crucial because the mind would have us believe that our evaluations
are actual descriptions. It is useful to notice this so we don’t fall into
that mind trap. Let’s take a look at what happens when we use
language to evaluate. Consider the question “Would you call this a
good or a bad chair?” People might answer with “This is a good
chair,” “This is a bad chair,” or “This is a gorgeous chair.” These
are evaluations, but they sound just like descriptions of the chair—
just like someone saying, “This is a wooden chair,” “This is a
brown chair,” or “This is a chair that doesn’t recline.” But can the
evaluations really be considered descriptions? Is “This is a good
chair” the same type of statement as “This is a wooden chair”? The
mind would have you believe so.
Now, notice that if we were all to leave this room and there were
no one here to evaluate the chair, it would still be “a wooden chair,”
“a brown chair,” and “a chair that doesn’t recline.” But it won’t be
“a good chair,” “a bad chair,” or “a gorgeous chair” anymore.
Our evaluations are not descriptions of the chair, or of any object or
any person. Our evaluations are within us. If everybody in the world
were to die tomorrow, the chair would still be wooden and brown,
but it wouldn’t be good or bad. Because of how language works, the
mind can obscure the difference between an evaluation and a
description. Both kinds of statements look the same: “This is a such-
and-such chair.” But if “good” and “bad” are seen for what they
are—mere evaluations, and not descriptions as the mind says they
are—that makes a huge difference. Evaluations aren’t real, like a
color, wood, or the mechanics of the chair. They’re just ideas or
opinions that exist in the mind. We don’t have to let them control our
behaviors. They are just thoughts.
3. Conduct an Experiential Exercise in Evaluations vs. Descriptions
Explain that everyone tends to engage in evaluation much of the time;
this is just how the mind works. Then ask group members to pair up and sit
across from each other. Explain that the task is for one person in each pair
to tell a story—perhaps about a recent event or interaction—for three
minutes. When the other person notices an evaluation, he or she is simply to
label it, saying only “evaluation” in a neutral, almost scientific tone. The
only word the listener is allowed to say is “evaluation.” The speaker is
simply to continue talking, without changing the subject to the listener’s
observations. The point is simply to gain some practice in noticing when
evaluations are occurring. After three minutes, have speaker and listener
switch roles and repeat the exercise.
Afterward, have group members share their experience without analysis
or interpretation. You might ask something like “What was your experience
of observing your evaluations?” Then point out that group members can use
a similar approach with their own evaluations and other thoughts, as well as
with physical sensations, emotions, and impulses. You can also highlight
how the approach in the experiential exercise is similar to some of the
defusion techniques covered in session 5:

Notice that you can do the same thing with your own evaluations
and other thoughts, as well as with emotions, impulses, and physical
sensations. You can say “emotion” when you notice an emotion, or
you can label specific emotions, saying, “That’s anger” or “That’s
shame,” or simply “sadness.” It’s like noticing what’s going on with
the weather: “Oh, it’s raining” or “It’s warm.”

4. Explore Self-Evaluations
The work on evaluations helps set the stage for exploring self-
evaluations. You can simply continue with the previous line of thought and
describe applying defusion techniques to self-evaluations:

If you notice a thought like “I’m an awful person,” you can name it
for what it is using one of the defusion techniques we talked about
last time. You can even add a description to help distinguish the
 evaluation. With “I’m an awful person,” you could first describe
yourself, saying, “I am a person,” and then add “and I am having
the evaluation that I am awful.” This sounds a bit weird, but that’s
the point. Because it’s odd, it disrupts the normal language
conditions that the mind uses to trick us. So if you notice that you’re
evaluating yourself or what you’re doing, or even evaluating your
evaluations, simply note that your mind has tricked you once again
and say, “Oh, there’s an evaluation,” one more time.

Take some time to explain why self-evaluations are a particularly

problematic type of thought:

Evaluations about ourselves are especially dangerous because they

can turn into labels about ourselves, who we are, and how we
“should” be. We start putting ourselves in boxes that limit our
choices. Sometimes our labels and self-evaluations come from
stories others have told us regarding who we are and how we should
be.
And while some of our self-evaluations are positive, like “I’m a
good student,” “I’m intelligent,” “I’m beautiful,” or “I’m funny,”
some of them are really negative, like “I’m ugly,” “I’m stupid,” “I
always fail,” or “People always leave me.” These labels can then
lead to rules aimed at maintaining our image of ourselves—rules
that tell us how we “should” behave or interact with others. But the
truth is, our sense of self and the stories we tell ourselves about
ourselves are constantly changing. Depending on your mood or the
day, you may choose to buy into different stories and labels about
yourself.

Use this explanation to lead into a whiteboard exercise exploring how

group members’ self-evaluations vary depending on the context. Start by
asking the group to give examples of their typical self-evaluations when
they’re in a great mood or feeling at their best. List a number of these, then
ask for examples of their typical self-evaluations when they’re in a bad
mood or feeling at their worst.
5. Cultivate Self-as-Context
Work on defusing from self-evaluations overlaps and leads naturally to
cultivating self-as-context, or the observer self. An experiential exercise
using the metaphor of a chessboard (and an actual chessboard) can be
useful here (Hayes et al., 1999). Ask for a volunteer to come up and do the
exercise. Have the volunteer list ten positive self-evaluations on one piece
of paper and ten negative self-evaluations on another. Keep the list of
negative self-evaluations and give the positive list to the volunteer. Sit
facing the volunteer with the chessboard between you, then begin putting
pieces on the board, alternating between the two of you and stating one of
the labels out loud each time.
Once all of the pieces have been placed, suggest that the person isn’t
any of the pieces, or even either of the players. Help the volunteer arrive at
the realization that he or she can be the chessboard, in contact with
thoughts, feelings, and other internal experiences without being them.
Here’s an example of how you might do so:

Some of these pieces are good, and some are very painful. We
humans struggle to get rid of all these painful thoughts and feelings
that show up when our schemas are activated. There are moments
when you feel insecure, and moments when you feel very confident;
moments when you feel competent, and moments when you feel like
a failure. There are moments when you feel awkward, and moments
when you feel real and genuine. But what if you weren’t these chess
pieces? What if you weren’t either the good pieces or the bad
pieces? Is there anything you could be besides these chess pieces?
(This isn’t a rhetorical question; elicit a response from the client.)
If you were a player, you could try to move these pieces around
in an effort to win, but that doesn’t change anything; the player is
still caught in the game and invested in whether the good or bad
thoughts and feelings win. The games just go on and on. Sometimes
the good pieces win, sometimes the bad. Can you think of anything
else you might be other than the pieces or the player? (Again, elicit
a response.)
Here’s an idea: What if you were the board? That way you could
have the pieces but not be the pieces. The board is in contact with
 the pieces. It’s aware of the pieces and experiences the pieces. But
the board itself never changes, whether there are more black or
white pieces and no matter where they move. The board stays the
same. It doesn’t care about the game or who wins or loses. So from
this space, the space of being the board, can you see how you can
hold all of your experiences, observing them and yet not being
them?

Visualization can also be very useful for letting go of self-evaluations

and cultivating the observer self. You can guide the group in a visualization
where they first think of a time when they behaved as their “worst self” and
did something they truly regret. Have them recall and observe specific
thoughts, feelings, and behaviors from that incident. Then guide them to see
that the part of themselves that observes their “worst self” is distinct and
separate from that self. Here’s a script for this exercise (based on Ciarrochi
& Bailey, 2008):

Close your eyes and take a few moments to notice your breath and
the sensations in your body.
Now think back to a time when you were at your worst…
Imagine, as vividly as you can, being this “worst self”… Notice the
feelings that push and pull at you. Notice how your “worst self”
thinks. Let yourself be aware of specific thoughts… See how your
“worst self” behaves with others and how far this is from your
values.
Now notice that, within you, there’s somebody looking at this
“worst self.” This is a self that watches your “worst self” and
witnesses everything it experiences. This part of you is the observer
self.
Even though your thoughts, feelings, urges, and sensations are
continuously changing, there is still a consistent you throughout.
There is a you that can watch all of your experiences without being
those experiences or struggling with them. Just become aware of
this person behind your eyes who watches your “worst self.” Can
you experience what it feels like to be the observer?
 Now consider this: If you can observe your “worst self,” then
you are not the same as that “worst self.” If you can observe the
thoughts and feelings connected to your worst self, then you aren’t
equivalent to those thoughts and feelings. You are the observer.
Remember the chessboard? You aren’t the pieces on either side,
fighting all those battles. You aren’t your thoughts, feelings, and
sensations. You are the one who observes, notices, and holds all of
these pieces.
Can you imagine that you are not your breathing and your body
and its sensations, that you are not your emotions or your thoughts?
Many parts of you have changed over the years. You have aged.
Your appearance has changed. Your thoughts and feelings are
constantly changing. But the observer self has always been there,
never changing. See if you can sense this deeper “you.” Think of
yourself as being like the sky, being an unchanging perspective from
which you notice and hold the ever-changing weather of your
awareness. See if you can let go of your attachment to and struggle
with difficult emotions, thoughts, sensations, and impulses.

Now notice all of the experiences that have shown up today—

particularly the difficult thoughts and feelings of your “worst self.”
And as you do, notice that you’re here now, watching all of it. See if
you can make space to be the observer right now. You are exactly
who you should be. Nothing needs to be changed. Nothing needs to
be fixed.

6. Assign Homework
Assign the following homework to be practiced throughout the week:

Ask group members to commit to following through on the valued

intention identified at the beginning of the session.

Have them notice when evaluations occur, and then practice

cognitive defusion techniques with these thoughts.
 Session 7
Like session 6, session 7 begins by checking in on how group members did
on following through on their valued intention for the week and setting a
new intention for the coming week. Sessions 5 and 6 focused primarily on
cognitive defusion techniques, although these techniques may have been
applied to other internal experiences as well, including emotions. From this
point forward, there will be more emphasis on emotions and emotional
exposure—facing the pain that comes up when schemas are triggered.
However, it’s essential to conduct exposure only with primary pain, which
is unavoidable and must be accepted, and not with secondary pain due to
maladaptive schema coping behaviors. Because anger shows up so often as
a schema coping behavior, this session focuses on anger so that the
exposure work in sessions 8 and 9 can target the primary pain beneath the
anger.

Procedures

1. Review group members’ experiences with the homework from session 6 and set a
new intention for the coming week (Valued Intentions Worksheet; 15 to 20 minutes).

2. Explore willingness via a discussion of the inevitability of pain and loss in

relationships (10 to 15 minutes).

3. Discuss anger as a coping strategy and explore the costs of anger (15 to 20
minutes).

4. Provide psychoeducation on anger (five stages of anger; 10 to 15 minutes).

5. Explore the costs of resentment (courtroom metaphor; 5 minutes).

6. Use a mindfulness practice and visualization to explore the moment of choice and
letting go of resentment (mindfully eating chocolate and visualizing a resented
person; 15 minutes).

7. Assign homework (5 minutes).

1. Review Homework
Ask group members to share their experience in following through on
their valued intention. Explore any barriers that came up and brainstorm
strategies to deal with those barriers, then have them set a new intention for
the following week. For those who didn’t follow through, it’s best to
continue working on the previously identified intention unless they have
determined that the intention doesn’t genuinely reflect their values.

2. Explore Willingness
To help group members develop willingness to face emotional pain,
begin by explaining that emotional pain is unavoidable in important
relationships:

All close relationships come with pain and loss. Schemas inevitably
get triggered in these relationships. You may feel hurt, rejected, or
misunderstood. You may feel attacked, unappreciated, or criticized.
Opening up and being vulnerable in relationships comes at the risk
of feeling these painful emotions. Never having to experience any of
the pain connected to your schemas means being alone in the world,
without honest, authentic, and supportive relationships, whereas
having caring, loving, intimate relationships means sometimes
having painful schema-driven thoughts and feelings. If you had a
choice, which would you choose? Would you be willing to
experience the pain, including disappointment, hurt, abandonment,
rejection, and all of those other difficult feelings if that would bring
you closer to having authentic and meaningful relationships?

3. Discuss Anger as a Coping Strategy

As mentioned, anger is a common schema coping behavior; therefore,
many group members may struggle with this way of reacting. Because you
must look beneath the anger to uncover the hidden, avoided affect, the
session now turns to exploring anger and developing alternative responses.
Here’s a script showing how you might address this topic:
One of the ways we cope when our schemas get activated in
relationships is with anger and aggression. This is the fight-or-
flight reaction at work. When you sense a threat, your body is wired
to either run and escape the situation or fight for survival. It’s a
protective evolutionary mechanism, and it’s useful when you’re
actually in a life-threatening situation, but it usually doesn’t work
very well in close relationships. In relationships, running away or
fighting back usually only makes the situation worse. Plus, it often
increases the likelihood that what you fear will actually come true.
Fighting may make others fight back; withdrawing may make them
give up on the relationship.
When the fight-or-flight system is activated, the heart starts
beating fast and pumping blood harder to prepare us for action. Our
thoughts, feelings, sensations, and urges are also caught up in the
fight-or-flight response. Everything seems urgent, and we feel highly
reactive.
What kinds of thoughts do you have when you get angry?
Typically, when we’re angry our thoughts are more judgmental,
hostile, suspicious, and fearful. Our fears are exaggerated and our
interpretations of other people’s actions and motives are skewed.
The impulse to act can feel so urgent that it may be difficult to take
even a brief moment to evaluate the long-term consequences and
costs.
The experience of anger is kind of like having a tornado in your
body pulling you to use old coping behaviors to escape the terrible
internal storm. Sometimes anger feels like a combination of forces,
pushing and pulling in different directions. But what if there’s
another way to deal with these moments? What if you could simply
notice the pull to engage in old coping behaviors to try to escape the
feelings and still make the choice to move in the direction of your
values instead? What if you could just stay with the storm and
observe it like you would a storm in the sky: just noticing the
feelings, sensations, memories, images, and urges that come up?
You may not be able to control those feelings, just like we can’t
control the weather. But you can remember that weather comes and
 goes—that the storm will eventually pass—and that in the
meanwhile you can choose not to react in ways you’ll regret later.

Guide the group in a discussion of how using anger as a coping strategy

has impacted their relationships, the people they care about, and
themselves. Here are some questions you might ask:

Have you used anger to cope with other, more painful feelings?

What kind of thoughts do you have when you get angry?

Does buying into these thoughts bring you closer to or take you
farther away from your values?

When you’ve used anger as a coping strategy in the past, what have
the consequences been? Are there benefits? Are there costs?

When you get angry, are you moving closer to or farther away from
your values?

Can you be productive when you’re angry?

Do you make good decisions in this mode?

4. Provide Psychoeducation on Anger

Provide psychoeducation to help group members understand anger,
observe their experiences with anger, and identify the moment of choice,
when they have the option of responding differently. Here’s an outline of
the five stages of anger (Eifert, McKay, & Forsyth, 2006) and how you
might explain them:

1. Emotions prior to anger: Anger is usually preceded by a feeling

like guilt, shame, anxiety, or a sense of defectiveness or deprivation.
These emotions are related to schemas, past experiences, and
assumptions about how you’re going to be treated. When you get
angry, which schemas have been activated? What emotions do you
typically feel before getting angry?
 2. Anger trigger thoughts: Anger is often triggered by certain types
of thoughts, such as judgments about others, “shoulds,” memories,
blaming thoughts, and suspicious thoughts. What kinds of thoughts
tend to trigger your anger?

3. Anger feelings: Once anger has been triggered, many other

emotions arise, such as shame, fear, feeling threatened, and feeling
helpless, along with physical sensations like trembling hands, rapid
heartbeat, and rapid breathing. What feelings and sensations come
up for you when you get angry?

4. Impulses to act: The feelings associated with anger create an urge

to act—often by engaging in old, problematic schema coping
behaviors and avoidance strategies. What do you feel an impulse to
do when you get angry?

5. Anger behavior: The final stage of an anger episode is what you

actually do in that situation. For many people, this means yelling,
attacking, accusing, blaming, and so forth, which are all schema
coping behaviors. How have you behaved in the past when you got
angry? What specific schema coping behaviors have you engaged
in?

Next, engage the group in a discussion of these five stages and what
they can control; in other words, where they can find the moment of choice.
Ask the following questions and allow group members to discuss them:

Keeping in mind that we can’t control other people’s behaviors,

what parts of the anger experience can we actually control? Can we
control our thoughts when we get angry—actually stop ourselves
from having certain thoughts? Can we control our feelings when we
get angry? Can we control the impulses that come up for us when
we get angry? Which of these five stages of anger can we control?

If group members don’t arrive at the correct answer (we can control our
behaviors), remind them of this before proceeding.
5. Explore the Costs of Resentment
Habitual anger tends to result in resentment, so this may be a significant
issue for group members. Because resentment (like schemas) is a long-term
pattern of thinking about and relating to others, letting go of it can be
challenging. Much of the remainder of the session is devoted to helping
group members with this. Begin by discussing resentment. The metaphor of
a courtroom can be helpful here:

When we feel that another person has hurt or harmed us and can’t
seem to let go of our anger, it can build into a long-term pattern of
resentment. With resentment, we end up hurting ourselves more than
anyone else. When we become invested in getting others to feel and
understand our pain or to take responsibility for our pain, we tend
to get stuck. Life becomes more about having others feel bad about
our pain and make up for that pain than about accepting and
healing our pain. This can hold us back from living the kind of life
we want to live, as our lives become more about getting revenge and
gathering evidence against the person who has hurt us, rather than
about taking steps toward our values.
It’s like life turns into a courtroom, and the main goal is to prove
the other person guilty—to make sure the person is convicted of the
crime and sentenced appropriately. We may devote ourselves to
carrying a briefcase of evidence everywhere we go and continue to
add more and more evidence. Eventually the briefcase becomes so
heavy that it bogs us down. Attempts at punishing others and
making them feel the pain and suffering they’ve caused us ends up
limiting our own movement and choices. Being so invested in
proving that they’ve wronged us ends up punishing us.
The question is, how can we move on and let go of our desire for
the other person to get it? How can we leave the briefcase of
evidence at home, knowing that it’s still there, that the crime hasn’t
been dismissed or discounted, but that it doesn’t have to be a burden
we must carry with us everywhere we go? We can acknowledge that
we’ve been hurt and wronged and that we still have the choice to
leave the evidence at home. This way we can live the life we want to
live, free from the burden of carrying this evidence.
6. Use Mindfulness and Visualization to Explore the Moment of Choice
The session concludes with a mindful eating practice to explore feeling
urges and resisting them, followed by an extended visualization on resisting
the impulse to act on anger and, ultimately, replacing resentment with
compassion. Begin by briefly explaining mindfulness of the anger
experience:

As we’ve discussed, when we get angry, we become reactive and

tend to act impulsively, but those impulsive behaviors have a high
cost in our relationships. So what can we do to slow things down so
that we can see what’s going on and make the choice to behave
differently? We can practice noticing our anger and all of the
different parts of it: thoughts, feelings, and urges. It’s especially
important to be aware of our urges and notice the moment of choice
that we have right after an urge comes up and before we act on it.
This is the moment when we can still choose different actions. In
some ways, this is a lot like observing and describing how
something tastes and the urge to chew or swallow, so let’s do a brief
mindfulness exercise with eating chocolate to explore how it works.

Give the group members each a small piece of chocolate and ask them
to notice every aspect of the chocolate. Before they put it in their mouths,
have them notice what it looks like, how it smells, and its temperature and
texture. Then have them put the chocolate in their mouths and observe how
it feels, its flavor, and, most importantly, the urge to chew or swallow the
chocolate. Ask them to let the chocolate melt in their mouths as slowly as
possible while noticing what it feels like to not act on an urge or impulse.
Help them identify this as the moment of choice, when they have an urge to
do something but can choose to do something else.
Next, conduct visualization that explores using a similar approach to
anger, having group members focus on a specific person whom they tend to
get angry with or resent. Here’s a sample script:

Now we’ll practice a similar exercise with anger. Close your eyes
and visualize a person you sometimes struggle with—a person you
think has wronged you in some way. Recall a specific incident with
this person—maybe an argument or other difficult interaction. Let’s
explore the anger slowly, just like we did with the chocolate. Hold
the image of the incident in your mind and notice all of the different
aspects of it. Where are you? Who are you with? What are you
saying? Notice the sounds, sights, and smells in that situation. Let
yourself feel some of the pain that this relationship causes you.
Bring your focus to any difficult or uncomfortable physical
sensations, perhaps in your stomach, chest, head, or shoulders.
Once you’ve identified a difficult physical sensation, raise a hand.
(Pause and wait for signals. Stay with this for a good while if group
members are having trouble.)
Now see if you can stop wrestling with that physical sensation
and just observe it. The point is not to like the feeling, but to
experience it as what it is: a sensation in a part of your body. Keep
noticing that sensation. See whether you can notice exactly where
that sensation is located in your body—where it begins and ends
and what shape it has. As you do this, see if you can drop any
struggle or sense of defense with this sensation and just have it as a
sensation… When you are a bit more open to this sensation, raise a
hand. (Pause and wait for signals.)
Notice any emotions that are arising. Maybe you’re feeling hurt,
shame, fear, or guilt.
Now gently turn your attention to your thoughts in this situation
with this person you have trouble with. Simply watch as judgments
and evaluations come up. Just notice and label them, then let them
go. You can say to yourself, “There’s a judgment” or “Thank you,
Mind, for that thought,” but then let it go without getting involved in
it. Just keep noticing judgments, stories, and criticisms and letting
go of each.
Now notice your impulses. How do you feel pulled to react in the
difficult interaction you’re imagining? Do you want to escape? Do
you feel an urge to attack? Notice the storm within, pulling you to
use old coping behaviors, and identify the specific behavior you’re
pulled to engage in.
 Now, as you’re observing all of the sensations, emotions,
thoughts, and impulses that your anger brings up in you, see if you
can notice whether this pain is connected to a schema. Also see if
you can notice any other emotions underneath the anger. Maybe you
were feeling shamed when you became angry. Maybe you were
feeling rejected when you became angry. Maybe you were feeling
criticized and your defectiveness schema was activated. When
you’ve identified a schema that has been activated, raise a hand.
(Pause and wait for signals.)
Now turn your attention to this person who you feel has done
you wrong. Notice his or her behaviors. Can you try to imagine
what schema might have been activated for that person? Maybe he
or she criticized you because of feeling rejected. Perhaps this person
feels guilt or shame and is blaming you for it. Maybe this person
feels unworthy and is trying to avoid that feeling by attacking you.
See if you can get a sense of what schema this person might be
trying to avoid.
Now I’ll ask you to see if you can find some empathy for this
person. Can you notice how the other person’s behaviors in that
situation brought more pain to him or her? Notice the other person’s
pain. See if you can begin to feel some acceptance of this person.
This is who the person is and how he or she is in the world.
Sometimes this person is difficult to be with because of struggling so
much to avoid his or her own pain. In this moment, see if you can
accept this person just as he or she is, even with the behavior that
brings you pain. See if you can extend compassion to this person
and let go of your anger and resentment.

Afterward, take a few minutes to discuss group members’ experiences

during the visualization.

7. Assign Homework
Assign the following homework to be practiced throughout the week:
 Have clients commit to following through on the valued intention
identified at the beginning of the session.

Encourage them to notice moments when schemas get activated,

then try to slow things down and identify related thoughts, feelings,
and urges. Ask group members to also notice their actual response
and whether they feel better or worse afterward.

Session 8
Session 8 also begins with checking in on how group members did on
following through on their valued intention for the week and setting a new
intention for the coming week. Having explored anger and the emotions
beneath anger in session 7, you can now turn to exposure to the primary
pain associated with schema activation. From this point forward, defusion
and exposure work proceed in tandem, as difficult thoughts often bring up
difficult emotions, and vice versa. To that end, session 8 includes a variety
of visualizations and experiential exercises with a focus on letting go of old
control strategies and not identifying with painful schema-related affect and
cognitions.

Procedures

1. Review group members’ experiences with the homework from session 7 and set a
new intention for the coming week (Valued Intentions Worksheet; 10 to 15 minutes).

2. Practice defusion through an experiential exercise in wearing labels (5 minutes).

3. Provide psychoeducation on emotions and the unworkability of control strategies

(understanding what we can and cannot control and that we can’t get rid of internal
experiences; 20 to 25 minutes).

4. Explore the costs of avoidance of painful emotions using an experiential exercise

(Exploring the Flip Side; 15 to 20 minutes).

5. Discuss the experience of defusing by wearing labels (5 minutes).

 6. Explore letting go of old control strategies using an experiential exercise (Dropping
the Rope; 10 to 15 minutes).

7. Conduct a visualization for developing the observer-self perspective and defusing

from schemas (visualizing schema-triggering events from various stages of life; 5 to
10 minutes).

8. Assign homework (5 minutes).

1. Review Homework
Ask group members to share their experience in following through on
their valued intention. Explore any barriers that came up and brainstorm
strategies to deal with those barriers, then have them set a new intention for
the following week. For those who didn’t follow through, it’s best to
continue working on the previously identified intention unless they have
determined that the intention doesn’t genuinely reflect their values.

2. Practice Defusion by Wearing Labels

Have group members select a particularly painful schema-related self-
evaluation. You might bring up the sales representative and ask them to
choose a self-evaluation that’s an especially pushy sales rep. Have them
write the evaluation on an index card and then tape it to themselves and
wear it as the session proceeds. Write and wear a self-evaluation yourself so
you can model the process and share some of the embarrassment.

3. Provide Psychoeducation on Emotions and Control Strategies

To help group members develop more willingness to have difficult
emotions, spend some time discussing emotions and the problems with
control strategies. A metaphor of a hungry lion (based on Hayes & Smith,
2005) can be useful in explaining the problems with efforts to control
internal experience. Here’s a script showing how you might cover these
topics:
We’ve been talking about emotions that come up for us related to
our schemas, such as shame, hurt, and anger. We’ve been exploring
how we’ve been relating to this pain. In the last session when we
were talking about anger, we explored whether we can really control
the pain or get rid of it and worked on learning to simply observe
our pain, watching it with acceptance and without trying to change
it. Just to be clear, this doesn’t mean condoning the pain or liking it;
it just means acknowledging the pain without trying to push it away.
This is a place where we can stop and observe our experiences and
urges without acting on them.
The Serenity Prayer, which is used in 12-step programs, can be
helpful here. It says, “God, grant me the serenity to accept the
things I cannot change, courage to change the things I can, and
wisdom to know the difference.” The most difficult part of this is
distinguishing between the things we can and cannot control. For
the most part, the things that we can control are our behavior, our
actions, and what we want our life to stand for—our values and the
choices we make. As far as the things that we cannot control, the list
is long, but some of the key things are thoughts, memories, bodily
sensations, urges, impulses, and feeling—and the behavior of others.
If you don’t like this chair, what can you do? You could pick it
up, just like this, put it outside, and get rid of it. You could throw it
out and permanently get rid of it. But what about your thoughts,
feelings, and memories? Can you do that with them? Why can’t you
throw thoughts out? Why can’t you permanently get rid of them?
Thoughts and feelings aren’t tangible objects. They can’t be held,
touched, or permanently moved. Controlling internal experiences
simply doesn’t work in the same way as controlling objects in the
outside world.
However, our culture gives us a lot of messages that we can
control our internal experiences in the same way as we can control
objects in our environment. We hear these kinds of messages all the
time: “Calm down,” “Don’t worry,” “Pull yourself together,”
“Chill out,” “Where there’s a will there’s a way,” and so on. As a
child, you learned not to touch a hot stove—to avoid it—and that’s a
good thing. But internal pain cannot be avoided. Yet we often try to
respond to emotional pain and other difficult internal experiences as
if they are a hot stove—as if thoughts, feelings, impulses, and
sensations can actually harm us, and as if we can avoid them.
We cannot arbitrarily choose to have more or less of any
emotion connected to our schemas. Since fear is an emotion that
comes up with most schemas, let’s use it as an example. Here’s a
little thought experiment that helps demonstrate the problem with
trying to control emotions. Suppose I tell you that in a moment a
lion will enter the room and that this lion preys only on people who
show fear or attempt to run away. This lion is incredibly sensitive
and will be able to detect the slightest trace of fear that comes up
for you. As long as you don’t feel afraid or try to run away, you’ll be
completely safe and the lion won’t eat you. But if you experience
even a trace of fear or try to run, the lion will notice this and eat
you.
What would happen? You’d probably start feeling terrified. Can
you control that fear? Can you make yourself not feel afraid? How
about running? Do you think you could control whether you’d run?
Can you make yourself not run? You’d probably be able to stop
yourself from running, but could you stop yourself from feeling
afraid in the same way?
Now think about what would happen if I told you that as long as
you pet the lion, it won’t eat you. What would you do? You’d
probably start petting it, right? What if I told you that as long as you
feed the lion, it won’t eat you? What would you do? You’d probably
offer it some food. The point here is that controlling our behaviors
and what we do with our hands and feet is very different from trying
to control our emotional responses. Thoughts, feelings, and
sensations aren’t like objects in the world. We can’t move them
around and control them.
Changing and controlling our behaviors is very different from
attempting to change our internal experiences. We simply cannot
relate to our internal experiences the way we do to objects in the
world. It just doesn’t work. Our thoughts, sensations, emotions,
impulses, and memories are in us, and we can’t run away or escape
from ourselves.
 Pain and suffering happen to 100 percent of people. At one point
or another, everyone feels disappointed, criticized, lonely, or sad.
Have you ever managed to permanently remove an emotion? Have
you been able to get a certain thought to never show up in your
brain again? It almost seems like the more you don’t want those
experiences, the more you have them. The more you don’t want to be
angry, the angrier you get. The more you don’t want to be depressed,
the more depressed you become. If you’re prone to anxiety, you
might start getting anxious about your anxiety. You might start
wondering, “Why am I anxious? Should I be this anxious? Where
did this anxiety start? Are other people as anxious as I am?” All of
that just builds more anxiety. In the end, struggling with difficult
emotions actually causes more pain.

4. Explore the Costs of Avoiding Painful Emotions

To help the group understand the costs of avoidance, conduct an
exercise similar to Exploring the Flip Side, in chapter 7. Ask for a volunteer
from the group to come up and do an exercise related to the thought that he
or she wrote on the index card that he or she is wearing.
Ask the volunteer which schema this thought might be connected to and
continue to write down more thoughts and feelings that are connected to
this schema on the volunteer’s index card. After you’ve written down five
or six thoughts and feelings on the card, put the card in front of the
volunteer, really close to the person’s face. Almost taunt the volunteer with
the card in an effort to get him or her to look away from it or physically
push it away. You can even read the card out loud, playing the role of the
volunteer’s mind while holding the card up in front of him or her. Ask,
“How do you usually relate to these thoughts and feelings when they come
up for you?”
Show the volunteer how he or she gets caught in the struggle of not
having certain thoughts and feelings and tries to push them away, avoid
them, or look away from them. Have the volunteer notice the struggle
involved in attempting to avoid these thoughts and feelings. Explore how
these thoughts and feelings may be functioning as barriers:
 Let’s look at the thought or feeling on this card. Has this thought or
feeling ever stopped you from doing something that was important
to you? What specific thing has this thought kept you from doing?

On the back of the index card write down the valued intention for which
this thought or feeling has been a barrier. Identify the related value and
write that as well, and have all of the group members do the same. Then
bring the front of the index card, with its schema-driven thought or feeling,
closer to the volunteer and help the volunteer see that the farther away he or
she pushes the pain, the farther away the value is:

What could you do with this card if you wanted to continue escaping
and running from this experience—if you wanted to get rid of this
thought or feeling? You can continue to try to push it away or even
throw it away. (Move the card farther away from the client, crumple
it up, or put it in the garbage.)
But have you ever managed to permanently remove this thought
or feeling? Have you managed to keep it far away from you? And if
you do toss this card away, even if it does get it farther away from
you, what else is farther away? What else is on that card? The
farther away that thought or feeling is, the farther away your value
is. The closer the thought or feeling is, the closer the value is. Can
you get closer to this value without getting closer to this pain? So
the question is, would you be willing to have the thought or feeling
on this card if it means that you’ll also be closer to the value that’s
on the other side?

Having suggested that the only way to be closer to the value is through
willingness to be closer to schema-related pain, help the group see how they
might make space for difficult thoughts and feelings. Take the volunteer’s
index card and place it on his or her lap. Ask what this feels like, then
explore defusion from difficult thoughts and feelings using questions such
as these:

How many words are there on the front of your card? How many
letters are there? What color ink are they written in? Can you read
 them backward? Can you have these letters and words and just
observe them? Can you have them just as they are, without pushing
them away or struggling?

Ask group members to carry the index card with them for the following
week as an exercise in having painful thoughts and feelings without buying
into them:

Now I’m wondering if you would be willing to take this card with
you and keep it in your pocket for the next week. Look at the thought
or feeling on the front once a day. Don’t argue with it. Don’t avoid
it. Don’t buy into it. Just look at it, stay in contact with it, and put it
back in your pocket. Would you be willing to do that? And how
about a further step? Would you be willing to commit to doing the
action on the back of that card, bringing the card with you as you
take that step?

5. Discuss the Experience of Defusing by Wearing Labels

Ask clients what it felt like to wear the labels with painful self-
evaluations. Ask whether their feelings or discomfort about the labels
changed over the course of the session or stayed the same. Did they forget
they were wearing these labels, or did they feel self-conscious about it
throughout the session?

6. Explore Letting Go of Control Strategies

The experiential exercise Dropping the Rope, discussed at length in
chapter 7, can help group members understand the limitations of control
strategies. It also helps demonstrate the benefits of behavioral flexibility in
the face of perceived barriers. In a group setting, ask for a volunteer to do
the exercise. You’ll need a somewhat short piece of rope—about six feet
long—for this exercise. Here are the specific steps:

1. Ask about a recent schema-triggering situation and have the

volunteer describe the associated feelings and thoughts, then
 objectify this schema-related pain by asking questions about its
shape, size, color, weight, texture, and so on. You can also ask
whether any of these physical qualities are changing or whether the
pain is moving in any way.

2. When the volunteer has clearly described the schema-related pain as

an object, explain that you’re taking the object out of him or her and
putting it in you. Act out this process of transferring the pain.

3. Hold one end of a rope and ask the volunteer to hold the other end.
Then inquire about how the volunteer has been relating to this pain
when it shows up.

4. Pull on the rope and let the volunteer struggle with you as the
schema-related pain. Remind the volunteer of the feelings and
thoughts. Pull the volunteer around or let him or her try to get away
by pulling you for a minute or two.

5. Encourage the volunteer to explore alternative solutions. If the

volunteer doesn’t come up with the idea of dropping the rope, solicit
additional solutions from the group. If necessary, you can eventually
suggest dropping the rope.

6. After the volunteer drops the rope, continue to represent the pain
and follow the volunteer around wherever he or she goes.

7. Help the volunteer notice that even after he or she drops the rope,
the schema-related pain is still there. However, the volunteer is now
free to move around, including toward important values. Even
though the pain is still there, the volunteer is setting the direction
rather than being constrained and locked in a struggle.

7. Conduct a Visualization for Developing the Observer Self

Another way to help group members develop the observer-self
perspective and disidentify with their self-evaluations and other schema-
driven thoughts and feelings is with a visualization that explores a recent
schema-triggering event and how it relates to similar situations earlier in
life. Then the visualization shifts to a recent positive experience to help
underscore how thoughts, feelings, and other private experiences are always
changing and therefore do not and cannot define us. Here’s an outline for
the visualization (based on Hayes et al., 1999):

1. Have group members sit comfortably and close their eyes.

2. Ask them to remember a moment during the past week when a

schema was triggered. Guide them in vividly recalling the incident
and all of the associated images, sounds, physical sensations,
emotions, and thoughts. Direct them to particularly notice thoughts,
stories, judgments, and predictions and whether these thoughts seem
familiar—like old, often-repeated stories.

3. Have them notice that the self observing the memory is the same as
the self in the memory.

4. Have group members let go of the recent memory and ask them to
try to recall one of the first times when the schema from that
memory was triggered and that familiar story began to arise—an
early experience perhaps with a parent or caregiver, at school, or
with friends. Guide them in vividly recalling the event and all of the
associated images, sounds, physical sensations, emotions, and
thoughts. Ask whether the stories connected to this early event seem
to manifest in current relationships, or whether they find themselves
trying to escape or avoid this experience of themselves. Ask them to
compassionately make space for this difficult memory and their
younger self and guide them in accepting all of these experiences,
perhaps using the metaphor of the sky and the weather.

5. Have them notice that the self observing this childhood memory is
the same as the self in the memory.

6. Have group members let go of that early memory and recall a recent
situation where they experienced thoughts and feelings opposite
those triggered by the schema—perhaps a situation where they felt
confident, secure, or loving toward themselves. Again, have them
bring to mind all of the details of the situation: where they were,
 who they were with, and what was said, along with the associated
images, sounds, physical sensations, emotions, and thoughts.

7. Finally, have them notice that the self observing this memory is the
same as the self in the memory—and in all of the memories brought
to mind in this visualization, both positive and negative.

8. Assign Homework
Assign the following homework to be practiced throughout the week:

Ask group members to commit to following through on the valued

intention identified at the beginning of the session, as well as the
intention on the index card to be carried over the course of the week.

Have them notice whether they can make space for any
uncomfortable feelings that come up while acting on values.

Session 9
Again, the session begins with checking in on how group members did on
following through on their valued intention for the week and setting a new
intention for the coming week. Because this is the next-to-last session, it
reviews many of the topics and skills from previous sessions and gives
group members an opportunity to practice and commit to new behaviors.
An important focus of this session is teaching group members effective
communication skills. This session isn’t as full as sessions 1 through 8,
creating some flex time to cover material that didn’t fit in earlier sessions.
You can also use the extra time to address any lingering issues group
members may be experiencing.

Procedures

1. Review group members’ experiences with the homework from session 8 and set a
new intention for the coming week (Valued Intentions Worksheet; 10 to 15 minutes).
 2. Conduct a visualization exploring reactions to recent schema-triggering events (5 to
10 minutes).

3. Discuss effective communication (A Formula for Effective Communication handout;

5 to 10 minutes).

4. Conduct a role-playing exercise to practice defusion and alternative responses to

the event visualized earlier in the session (Defusion Skills handout; 45 minutes).

5. Conduct a visualization bringing mindfulness and compassion to schema-related

pain, again exploring the event visualized earlier in the session (5 minutes).

6. Assign homework (5 minutes).

1. Review Homework
Ask group members to share their experience in following through on
their valued intention. Explore any barriers that came up and brainstorm
strategies to deal with those barriers, then have them set a new intention for
the following week. For those who didn’t follow through, it’s best to
continue working on the previously identified intention unless they have
determined that the intention doesn’t genuinely reflect their values.

2. Conduct a Visualization Exploring a Recent Schema-Triggering

Event
Ask the group to close their eyes and visualize a recent event in which
their schemas were triggered in an important relationship and they didn’t
respond in a way that aligned with their values. As always with
visualization, provide guidance on attending to visual, auditory, kinesthetic,
and other sensory aspects of the experience. Ask them to see where they
were, hear what was said, and notice what they felt physically—both at the
time and in the moment, during the visualization. Have them observe
thoughts and feelings as well, then help them turn their attention to urges,
impulses, and their actual behavior. In the process, you can revisit the
moment of choice, underscoring that it isn’t necessary to act on behavioral
urges, and guide the group toward assessing the costs of continuing to resort
to old coping behaviors:
 How are you pulled to behave? What do you want to say or do?
Notice that you don’t have to act on any impulse. You can watch the
urge to engage in old coping behaviors while still keeping your
commitment not to do so. How did you actually behave? What did
you say and do? What was the impact on the other person? Did it
make your relationship closer, or did it create more distance? Slow
everything down and just watch the scene unfold in slow motion.

Afterward, explore what this experience was like for the group. Have
group members envision a values-based response to the situation. What
would they have liked to do differently? How could they have behaved in a
way that would enhance the relationship?

3. Discuss Effective Communication

An optional module of the group protocol (absent from the individual
protocol) is assertiveness training. It is included here because clients treated
in a group setting often display poor interpersonal skills. When schemas are
triggered, these clients frequently lack the ability to communicate their
needs and feelings effectively.
If covering effective communication in group therapy, give group
members the handout A Formula for Effective Communication.

A Formula for Effective Communication

Here’s a straightforward formula for communicating effectively and making assertive

requests. Simply fill in the blanks as appropriate to your situation:

1. When [describe the specific event objectively and nonjudgmentally],

2. I felt [describe how you felt].

3. I need [describe your need in terms of values] (for example, “I need connection,
[respect, honesty, and so on]”).
 4. Would you be willing to [specific request describing how this person can meet your
need]?

Here’s an example:

1. When we had plans to meet at two in the afternoon on Saturday and you showed
up a half hour late,

2. I felt hurt and concerned.

3. I need to be able to count on you and trust you.

4. Would you be willing to be more prompt in the future and make sure that you follow
through with our plans?

4. Conduct a Role-Playing Exercise to Explore Alternative Responses

Ask a volunteer to come up to the front of the room to role-play the
situation from his or her visualization and practice responding differently.
Ask for details about the event so you can role-play the other person in the
situation. Provide the volunteer with a copy of the Defusion Skills handout.
Ask the volunteer to use mindfulness and defusion skills—and effective
communication skills as needed—to respond in a way more aligned with his
or her values and in a way that will enhance the relationship.
Afterward, engage the group in a discussion about the role play and ask
group members to share the values-based behaviors they wish they had used
in their visualized situations. Ask them to set an additional intention,
beyond those committed to at the beginning of the session, to act on a
specific value in an important relationship. Have them write this intention
down.

5. Conduct a Visualization Bringing Mindfulness and Compassion to

Schema-Related Pain
To conclude the session, conduct a visualization bringing mindful
attention to the schema-related pain associated with the event visualized
throughout this session. The goal of the visualization is to help group
members open to acceptance and willingness with painful emotions and to
help them extend compassion to themselves. Here’s a script you might use:

Get comfortable in your chair and gently close your eyes. Begin by
focusing your attention on your breathing for a few breaths.
Now recall that moment when your schema was triggered in an
important relationship—the event you’ve been visualizing
throughout this session. Maybe you felt deprived, abandoned,
defective, or ashamed. Try to contact the core feeling in that moment
when the schema was triggered. Where in your body do you
experience that schema feeling?
Look back and try to recall how many times that feeling came up
for you today. How many times over the past week? How many times
over the past month? Try to see if you can recall the very first time
you had this feeling or one of the first times you had it. When you
have that earliest memory in mind, raise a hand.
Has this feeling been with you for a long time? Does it come up
in many different relationships? How have you related to this
feeling? Stay with this pain and breathe with it. If you notice any
urges to escape or push away this experience, just notice that urge
and see if you can allow yourself to stay with this experience. What
does it feel like to fully experience this feeling without struggling?
Can you allow yourself to feel 100 percent of your experiences with
compassion and gentle kindness toward yourself? Can you make
space for all the parts of your experience? Does this experience
have to be pushed away or avoided? Or is this pain something you
can handle—something you can observe nonjudgmentally and fully
experience?
Notice any thoughts, emotions, sensations, and urges that are
coming up or getting more intense and just observe them all with
kindness and willingness, as if this schema-related pain is a crying
baby. See if you can allow yourself to invite this pain in and
embrace it as a part of you, a part that’s always been there with you
and always will be there. Nothing needs to be fixed; nothing has to
be changed. You are exactly where you should be. When you are
ready, gradually widen your attention and slowly open your eyes.
6. Assign Homework

Have clients commit to following through on the valued intention

identified at the beginning of the session, as well as the new
intention in an important relationship, established after the role play
on alternative responses.

Ask group members to practice willingness to feel schema-related

feelings while not acting on the related behavioral impulses.

Encourage them to look for opportunities to practice alternative,

values-based responses to schema-triggering situations.

Session 10
As with session 9, this final session isn’t as full as the first eight, creating
some flex time to cover material that didn’t fit in earlier sessions and to
address any lingering issues group members may be experiencing. This
concluding session begins with an expansive mindfulness exercise that
continues the work of fostering self-compassion and compassion toward
others as an avenue toward healing. Time is devoted to exploring members’
experiences in the group, and then group members are given a final
opportunity to practice alternative responses. The main priority of this
session is giving group members the opportunity to come up and practice
new values-based behaviors and get feedback from the group. The session
concludes with an exploration of potential barriers and planning strategies
that will allow group members to follow through with committed actions in
spite of these barriers.

Procedures

1. Conduct a mindfulness meditation promoting self-compassion and compassion

toward others (5 minutes).

2. Review group members’ experiences with the homework from session 9 (10
minutes).
 3. Discuss group members’ experiences over the past ten weeks (10 to 15 minutes).

4. Conduct a role-playing exercise to practice defusion and alternative responses to

specific schema-triggering events (Defusion Skills handout and A Formula for
Effective Communication handout; 35 minutes).

5. Discuss potential barriers and develop strategies for acting on valued intentions in
spite of barriers (15 minutes).

6. Have group members commit to a new intention (10 minutes).

7. Administer post-treatment assessments.

1. Conduct a Mindfulness Meditation Focused on Compassion

Helping group members build compassion for themselves and others
will increase their willingness to be present with their own pain and the pain
of others. This acceptance of schema-related pain is a necessary step in
taking action in valued directions. Here’s a script for a visualization to build
compassion (Eifert and Forsyth, 2005):

Start by closing your eyes and turning your attention to the natural
rhythm of your breath. You need not control your breath in any way.
Just tune in to your body and your breath.
Now bring to mind a moment when a schema was triggered in a
relationship. Get in touch with the pain and hurt that this schema
brings up in you. Then, with your next inhalation, breathe in all of
the negativity and pain. Breathe in that discomfort with the
realization that what you are feeling at this very moment is being felt
by millions of people all over the world. You are not alone with this.
Everyone has schemas. Everyone feels hurt, rejection, shame, and
fear in relationships. This pain is part of being a human being in
this world. Someone in the world is probably experiencing this same
pain, right now, this very moment.
Allow yourself to breathe in this pain more deeply. With each
breath, breathe in your pain, as well as the pain and suffering of
others who are experiencing pain. Make space in your body for all
of the pain that comes with the experience of being human.
 Now, with each exhalation, breathe out relief, compassion, and
kindness to others who are suffering. Continue opening up the space
inside you to breathe in more of this pain—your own and that of
others—and each time you exhale, breathe out relief, tenderness,
and compassion. Find the natural rhythm of your breathing. Then,
each time you inhale, open yourself up and be more willing to make
space for all your experience. You don’t have to push away and
escape the hurt and pain that shows up for all human beings. We
were made to handle and contain all of these experiences.
Now, whenever you’re ready, gradually open your eyes with the
intention to continue practicing kindness and compassion toward
the pain of humanity.

2. Review Homework
Ask group members to share their experience in following through on
their valued intention and discuss any barriers that came up. (Later in the
session, you’ll conduct a thorough discussion of potential future barriers
and strategies to deal with them and also ask members to commit to a new
intention.)

3. Discuss Members’ Experiences in the Group

Engage in a group discussion regarding group members’ experiences
with the group in general and with exploring and acting on their values.
Explore which strategies worked for them and which didn’t work so well.
Ask what they feel they’ve gained and what was difficult for them. Ask
them to share anything that they learned about themselves or their behaviors
in relationships. Also ask what they feel they still need to work on and what
values they’re going to continue to act on. Encourage group members to
continue to identify valued intentions and follow through with them on a
weekly basis.

4. Conduct a Role-Playing Exercise to Explore Alternative Responses

 Reprise the role-playing exercise from session 9, asking for volunteers
and using schema-triggering events that occurred over the past week. With
each volunteer, begin by asking the person to role-play his or her old,
maladaptive coping behavior, then have other group members give
feedback and offer suggestions regarding new, values-based behaviors.
Next, do the same role play again, but this time with the volunteer
practicing a values-based response characterized by honest and effective
communication and vulnerability. (If necessary, give group members the
handouts Defusion Skills and A Formula for Effective Communication.)
Ask each volunteer in turn to explore the old and new behaviors and what it
felt like to behave differently.

5. Discuss Potential Barriers and Strategies for Working with Them

To conclude the session, explore difficulties with willingness and
committed action. Ask group members to identify current barriers to valued
intentions. Spend some time discussing strategies for following through on
valued intentions despite these barriers. Then devote some time to exploring
possible future barriers and having group members suggest strategies for
those. Have group members predict future situations where their schemas
might get triggered and what new coping strategies they will use to ensure
they seize the moment of choice and respond based on their values, rather
than reacting based on old, maladaptive schemas.

6. Have Group Members Commit to a New Intention

Finally, have group members come up with a commitment to values-
based behavior in a frequently encountered triggering situation. Then have
each group member stand up and share that commitment.

7. Administer Post-Treatment Assessments

If you chose to administer any pre-treatment assessments for use as
outcome measures, have group members complete those questionnaires
again at the end of the session.
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Matthew McKay, PhD, is professor at the Wright Institute in Berkeley,
CA. In private practice, he specializes in the treatment of anxiety,
interpersonal problems, and depression. He is coauthor of The Relaxation
and Stress Reduction Workbook, Thoughts and Feelings, Self-Esteem, Your
Life on Purpose, and many other titles. Combined, his books have sold
more than three million copies.
Avigail Lev, PsyD, is clinical supervisor at the Berkeley Cognitive and
Behavioral Therapies Clinic. She specializes in couples therapy and treating
mood disorders and interpersonal problems.
Michelle Skeen, PsyD, studied schema therapy under Jeffrey Young. She
completed her postdoctoral work at the University of California, San
Francisco, and maintains a private practice in San Francisco, CA, where she
lives and works. She hosts a radio show and is author of The Critical
Partner. www.michelleskeen.com
Foreword writer Steven C. Hayes, PhD, is University of Nevada
Foundation Professor of Psychology at the University of Nevada, Reno. He
is author of hundreds of scientific articles and many books, including
Acceptance and Commitment Therapy, Relational Frame Theory, and Get
Out of Your Mind and Into Your Life.