Question: Can we use the choice point with chronic pain,

illness, injury, impairment – when clients see their choice as

limited? Might they react negatively to the idea of ‘choice’?
Answer:

FLEXIBLE LANGUAGE

Keep in mind, we can freely modify ALL language in ACT; so if you think terms like
‘choice’ or ‘choice point’ (CP) may not appropriate, no need to use them. You can
refer to the CP as a ‘map’ or ‘road map’ or ‘guideline’ for therapy:

‘So can we take a few moments to map out what’s going on for you with XYZ and
how this approach can help, so we can use it as a rough guideline for working
together?’

Similarly, if you’re not keen on it, there’s also no need to use the term ‘choice’, as
we’ll see shortly.

DECONSTRUCTION

With the CP we can take literally any clinical problem and rapidly “deconstruct it”
into the same four elements:

• Difficult situations (This includes work, relationship, financial, legal, or

medical problems. A medical condition, or physical injury, or physical
impairment would also go here.)

• Difficult private experiences (including cognitions, emotions, feelings,

sensations, urges, images, memories etc.)

• Inflexible responding to private experiences (“getting hooked”: fusion or

avoidance or both)

• Problematic overt or covert behaviours, resulting from fusion or avoidance

or both (away moves)

Now, if you're talking about a DSM diagnosis, such as ‘chronic pain syndrome’, it's
best to first 'deconstruct' it on the choice point. Plot the difficult thoughts,
feelings, and pain sensations at the bottom, along with the situations they find
most difficult; then plot the problematic overt & covert behavioural repertoires on
the away arrow. (The same applies to any DSM diagnosis: deconstruct it by
putting difficult thoughts & feelings & situations at the bottom, overt & covert
behaviours on the away arrow.)

However if you’re talking about a medical condition (e.g. cancer), a physical

impairment (e.g. paraplegia), an injury (e.g. a broken leg), that would go at the
bottom of the choice point as a ‘difficult situation’ (e.g. living with paraplegia,
getting treatment for cancer), followed by all the difficult thoughts, feelings, and
situations that go with it, and all the away moves that occur when hooked by
those difficult thoughts and feelings.

© Russ Harris 2024 Psychwire.com/Harris

NO MENTION OF ‘CHOICE’

In both cases above, there is absolutely no need to ever mention the word ‘choice’
when plotting this out. We may say:

'When these thoughts & feelings & physical sensations show up, they jerk you
around like a puppet on a string - bring you down, hold you back, pull you into
doing these away moves -taking you away from the life you want to build, and the
person you want to be. So a big part of our work involves learning 'unhooking
skills': how to unhook yourself from these painful thoughts and feelings and
physical sensations, how to take the power out of them, so they can't keep jerking
you around.'

So … no need to use the word ‘choice’, right? But if you want to use it, you could
say:

'If we don't have good unhooking skills, we have little or no choice about what we
do when painful thoughts & feelings arise; they completely, utterly dominate us.
But as we develop our unhooking skills, we have more choice about what we do
when those painful thoughts and feelings arise.'

THE AWAY ARROW

Next, without mentioning the word ‘choice’, we can explore the towards arrow.
We may say:

‘So can we spend a few moments looking at towards moves - things you want to
start doing, or keep doing, that involve taking good care of yourself, improving life
in little ways where possible, behaving more like the person you want to be?’

If clients have no idea, we may say: ‘Can I start you off: how about we write down,
“coming to therapy”, and “learning unhooking skills”?’ If these are the only two
away moves we can establish up front, that’s enough to start with (and it
indicates our next steps: creative hopelessness => dropping the struggle =>
teaching defusion/acceptance skills).

However, keep in mind, we can now bring in any of those questions we typically
ask to establish behavioural goals - and they’ll usually generate useful towards
moves. This may include seeing other health providers, and lifestyle changes
involving diet, exercise, sleep hygiene, etc.

And remember: if we’ve already established behavioural goals, prior to

introducing the CP, we can write those in.

SUMMARY WITHOUT MENTION OF ‘CHOICE’

With all this in place (and still no mention of ‘choice’) we can summarise:

‘So all this difficult stuff is showing up (pointing to the bottom of the choice
point). And it’s bloody painful. You’re dealing with a lot. And (still pointing to the
bottom of the choice point) when this kind of stuff shows up in our lives, no
matter what it is, and no matter who we are, we’ve all got two ways of dealing

© Russ Harris 2024 Psychwire.com/Harris

with it: towards moves, that help us move towards a better life - and away moves,
that take us away from it. Unfortunately, the default setting for all of us, is when
these difficult thoughts & feelings & sensations show up, we instantly get hooked
by them, and pulled into away moves. It happens automatically, before we even
realise it. That’s why I said, a big part of our work here is to learn ‘unhooking skills’
so we can do less of the away moves, and more towards moves.’

SUMMARY MENTIONING ‘CHOICE’

However, if we want to use the word ‘choice’ we could say:

Unfortunately, the default setting for all of us, is when these difficult thoughts &
feelings & sensations show up, we instantly get hooked by them, and pulled into
away moves. We have no choice about it. It happens automatically, before we
even realise it. That’s why I said, a big part of our work here is to learn ‘unhooking
skills’. When we can unhook, we have more choice about what we do; we don’t
necessarily have to do those away moves. When we’re unhooked, it’s easier to
choose towards moves. But when we’re totally hooked, we have no choice.’

VALIDATE BARRIERS

Whether or not we introduce the CP or use the word ‘choice’, it’s essential we
validate the barriers imposed by the client's chronic pain/impairment/injury, and
clarify our role:

'So there are all sorts of things you can't do right now, because of XYZ (client's
chronic pain/impairment/injury). And we don't know how long it will be before
you can do those things again; but we do know it's unlikely the next few hours or
days. And you have other professionals you're working with to help you with that -
your doctor, physio, etc - so our aim here is a bit different. Given there's so many
things you CAN'T currently do, our aim is to help you do whatever you possibly
CAN do- no matter how small it may be - to make your life as good as it possibly
can be, right now, in the face of all these challenges. And one of the main things is
learning new skills to unhook from all those difficult thoughts and feelings and
sensations you're struggling with.'

© Russ Harris 2024 Psychwire.com/Harris