Acceptance and Commitment Therapy for the Treatment of Generalized Anxiety

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

Sessions should follow the following format:

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

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

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

Session 1
• Objectives: The objective of this session is to fully understand the nature of the client’s
anxiety as well as to do an inventory of the previous coping strategies used to deal with
the anxiety. The therapist should also aim to induce Creative Hopelessness by focusing
on the relative failure of past attempts and the possibility that control is an “unworkable
system.”
• Potential supporting exercises:
o Solicit basic goals from the client
o Solicit past attempt to cope with anxiety
o Treatment Model Handout
o Digging out of the Hole Metaphor (text p. 101-104)
o Introduce the idea of the “unworkable system”
o Option to continue with “control as the problem” (time permitting)
• Homework:
o What Have I Given Up for Anxiety? Handout
o Mindful Worry Sheet (MWS)

Session 2
• Objectives: The objective of this session is to elaborate on the prior session’s conclusion
that control strategies are an “unworkable system” and to use experiential exercises to
test the efficacy of control strategies. Therapist should introduce the idea that “control is
the problem, not the solution.” To the extent that it applies, help the client appreciate
worry as a strategy that promotes the avoidance of imagery that is associated with more
intensive negative affect.
 • Potential supporting exercises:
o Control as the problem/Control of private events (manual p.46)
o ACT conceptualization of GAD (Eifert & Forsyth, 2005, p. 27)
o Polygraph Metaphor (text p. 123)
o Chocolate Cake Exercise (text p. 124)
o Tug of War with Monster (text p. 109)
o Option to continue with Willingness (time permitting)
• Homework:
o Mindful Worry Sheet (MWS) Handout

Session 3
• Objectives: The objective of this session is to continue to drawn on the client’s
experience to strengthen the recognition that “control is the problem,” that worry is an
avoidance strategy, and to introduce Willingness as an alternative to control. Finally, the
therapist should introduce and establish an emphasis on the importance of cultivating
mindfulness.
• Potential supporting exercises:
o Willingness as an alternative to control: Two Scales Metaphor (manual p.62)
o Willingness Handout
o Clear vs. Muddy Emotions
o Unwanted Visitor (a.k.a. Joe the Bum (manual p.65)
o Introduce Mindfulness with Mindful Breathing exercise (manual p. 24)
o Review Treatment Model Handout
• Homework:
o Read “What is Mindfulness?” Handout
o Function of Worry Handout (if appropriate)
o Mindfulness Breathing Exercise Handout with assignment for practice
o Practicing Mindfulness Handout
o Mindful Worry Sheet (MWS)

Session 4
• Objectives: The objective of this session is to build on an orientation to developing
mindfulness skills, as an alternative to worrying as an avoidance strategy. The concept of
Defusion should also be introduced.
• Potential supporting exercises:
o (Start with) Mindfulness Breathing Exercise (manual p.27)
o Leaves on a Stream (Mindfulness) (manual p. 90)
o Milk, Milk, Milk Exercise (text p. 154)
• Homework:
o Continued Mindfulness practice
o Mindful Worry Sheet (MWS)
 Session 5
• Objective: The objective of this session is to introduce the importance of values and how
they are distinct from goals, as well as to establish some simple behavioral goals in the
service of the identified values.
• Potential supporting exercises:
o (Start with) a Mindfulness Exercise**
o Introduction to values ( manual p.53)
o Discuss relationship between goals and values
o Choosing values: Choices vs. Judgments/Decisions (manual p.70)
o Identification of values: Tombstone Exercise (Handout)
o Identify a valued action (behavioral goal) to perform this week
• Homework:
o Values Identification Worksheet
o Mindfulness Practice
o Performance of identified valued action

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

Session 6
• Objectives: The objective of this session is to continue to build an orientation to
mindfulness and to introduce additional practical ways to foster defusion.
• Potential supporting exercises
o (Start with) Mindfulness Breathing Exercise (manual p.27)
o Skills of Mindfulness Handout
o “And” versus “but” (manual p.78)
o “I’m having the thought that . . .”
o Raisin Mindfulness exercise (manual p.27)
• Homework:
o Mindfulness Practice
o Mindful Worry Sheet (MWS)
o Identify a valued action (behavioral goal) to perform this week

Session 7
• Objectives: The objective of this session is to consider the functions of emotions, our
habit of emotional avoidance, and the distinction between Clear vs. Muddy emotions.
• Potential supporting exercises
o (Start with) Mindfulness of Sounds exercise (manual p.35)
o The Function of Emotions Handout and discussion
o Control of Emotion Cycle Handout
o Emotional Avoidance (Hot Stove Analogy) (manual p.35)
o Clear versus Muddy emotions (manual p.39)
• Homework
o Mindfulness Practice
o Identify a valued action (behavioral goal) to perform this week
Session 8
• Objectives: The objective of this session is to introduce the distinction between the
observer and conceptualized selves, and to recognize the connection between self-
conceptualizations and anxiety and worry.
• Potential supporting exercises:
o (Start with) a Mindfulness Exercise
o Discussion of conceptualized vs. observer self (text p.184)
o Observer Self Exercise (manual p.60)
o Identify a valued action (behavioral goal) to perform this week
• Homework
o Mindfulness Practice
o Performance of identified valued action

Session 9
• Objectives: The objective of the session is to introduce the idea of commitment as a
means to move towards identified values and to strengthen choices to achieve identified
goals. This serves to undermine the perpetuation of anxious worry and avoidance.
• Potential supporting exercises
o (Start with) a Mindfulness Exercise
o Coke or Pepsi Exercise (manual p.70)
o Commitment as a process (manual p.71)
o Identification of actions steps (smaller goals in the service of the larger ones)
o Gardening Metaphor (manual p.72)
o Barriers to goals and willingness to accept them: Bubble in the Road Metaphor
(manual p.72)
o Passengers on the Bus (manual p.73)
o Identify a valued action (behavioral goal) to perform this week
• Homework:
o Mindfulness Practice
o Performance of identified valued action

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

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

Session 11
• Objectives:
o To teach the client to be his or her own therapist.
o To maximize the likelihood that the client will continue to apply skills learned in
therapy after termination.
o To differentiate between a lapse and a relapse
o To normalize low to moderate levels of worry and anxiety
o To address client’s concerns about termination, if applicable.
• Potential supporting exercises:
o Path Up the Mountain Metaphor (text p.222)
o Relapse Prevention
o Preparation for Termination
• Homework:
o Develop a post-treatment plan
o Record goals for self (i.e., in 1 month, 6 months, 1 year)
o Identify a valued action (behavioral goal) to perform this week

Session 12
• Objectives:
o To reflect on progress made and the client’s continuing goals.
• Potential supporting exercises:
o Relapse Prevention
o Review and refine post-treatment plan
o Treatment Review Handout
o Treatment Summary Handout
o Termination

References

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

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

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

Metaphor Description Prompts

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

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

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

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

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

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

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

meditation practice.

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

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

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

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

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

Path Up the Mountain Metaphor (text p.222) – This metaphor involves seeing one’s path up a
mountain form the perspective of someone watching from afar on a different mountain.
Two Scales Metaphor (manual p.62) – We have two scales, anxiety/depression and Willingness,
but we only have control of the latter.

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

Control of Emotion Cycle Handout

Daily Experiences Diary
Function of Emotions Handout
Function of Worry Handout (if appropriate)
Mindful Worry Sheet (MWS)
Mindfulness Breathing Exercise Handout
Mindfulness Practice
Practicing Mindfulness Handout
Skills of Mindfulness Handout
Tombstone Exercise
Treatment Model
Treatment Review
Treatment Summary
Valued Directions Worksheet
What Have I Given Up for Anxiety?
“What is Mindfulness?” Handout
Willingness Handout