ACTProtocol VAMHCS

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Acceptance and Commitment Therapy Group Therapy Protocol

Addictions Intensive Outpatient Program
PTSD/Substance Use Dual Diagnosis Program

[Unpublished Therapy Manual. 2007]

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Author Acknowledgements

VA Maryland Health Care System
Acceptance and Commitment Therapy (ACT) Team

Minu Aghevli
Sonja Batten
Paul Benson
Melissa Decker
Jason DeViva
James Finkelstein
Sharon Kelly
Valdone Kuciauskas
Carol Mahoney
Mark Mann
Sarah Moeller
Lorie Morris
Sushma Roberts
Andrew Santanello

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Acceptance and Commitment Training (ACT)
Program Philosophy Statement

Pain is inevitable, suffering is optional.
-- Sylvia Boorstein

We know that individuals with substance abuse problems or PTSD have a tendency to
avoid painful memories and engage in behaviors to distance themselves from their pain.
Although these strategies may have worked in the short term, we believe that efforts at
avoidance are ineffective, and even harmful, in the long run. This program is about
becoming willing to make more space in our lives so that we are able to hold all the
painful thoughts, memories and experiences life has dealt us without dodging them
through the use of substances, AND at the same time move in the direction we value.

We strive to find meaning in our lives by letting ourselves and others know what is really
important to us what we value most. This treatment isnt about what is good or
bad, or what is right or wrong; the most important question at stake here is, How
well has this been working for me? One of our most important tasks is to honestly take
stock of what actions, relationships and life activities will help us live a vital and valued
life. For many of us, past or present behaviors such as substance use, avoidance due to
PTSD, or other difficulties may be causing us to behave in a way that is out of line with
our values.

In all of our activities in the ACT Program, whether they be group therapy, individual
counseling, or informal interactions with each other, we will work on:
Willingness to experience the full range of feelings, memories, and thoughts that
we have on a daily basis, without attempting to get rid of or avoid those that we
find difficult or uncomfortable
Being able to make an honest evaluation of our actions and beliefs in order to
determine how well they are working
Coping skills as alternatives for avoiding or using substances
Developing and participating in a social network
Commitment to moving forward in our lives, in a direction determined by our
individual values

This treatment is about living in a way that is rich, full, and vital, and that lines up with
our values. In this program, we choose life.

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Table of Contents

Title Page 1

Authors 2

Mission Statement 3

Week One: Radical Hope

Monday Curriculum
Quiet Reflection 4
Group Outline 5
Homework Assignment 11

Wednesday Curriculum
Quiet Reflection 12
Group Outline 13
Journal Group Assignment 16

Friday Curriculum
Quiet Reflection 17

Week Two: Control Versus Willingness

Monday Curriculum
Quiet Reflection 18
Group Outline 19

Quiet Reflection 23
Group Outline 24

Friday Curriculum
Quiet Reflection 28

Week Three:

Monday Curriculum
Quiet Reflection 29
Group Outline 30

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Quiet Reflection 34
Group Outline 35

Friday Curriculum
Quiet Reflection 40

Week Four:

Monday Curriculum
Quiet Reflection 41
Group Outline 42

Quiet Reflection 46
Group Outline 47

Friday Curriculum
Quiet Reflection 52

Week Five:

Monday Curriculum
Quiet Reflection 53
Group Outline 54

Quiet Reflection 58
Group Outline 59

Friday Curriculum
Quiet Reflection 63

Patient Handouts 64

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Monday Quiet Reflection

Workability Quotes

"Life is "trying things to see if they work."
Ray Bradbury

I cannot say whether things will get better if we change; what I can say is they must
change if they are to get better.
Georg Christoph Lichtenberg

If the only tool you have is a hammer, you tend to see every problem as a nail.
Abraham Maslow

The definition of insanity: Doing the same things youve always done and expecting
different results.
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Monday Curriculum

Group leaders will need a shovel for the group.

Philosophy Statement
Read over the program philosophy statement (See Page 3). Have one person stand up and
read each paragraph.Ask group participants to reflect on what they connected with in the
statement. Ask if there's anything that surprises or scares them in that statement. Allow
for discussion and sharing between the patients. This process generally takes about 20
minutes.

Read the three Quiet Reflection quotes (See page 6) and ask the group which one they
relate most to. For the first quote, point out the playful nature of trying new solutions. For
the second quote, try to have people reflect on the necessity of change, even if the
outcome is not promised. For the third quote, point out the need to use the right tool for
the right job (This can be helpful to set up for the digging part of the person in the hole
metaphor). This process generally takes about 10 minutes.

Next, present the Man in the Hole metaphor. Ask people to respond to the metaphor and
try to get people to focus on the need to put down the shovel, even if you don't know
what you're going to do next.

Life is one damn thing after another. Our job is to make sure its not the same
damn thing after another.

Man In The Hole Metaphor
The situation you are in seems a bit like this. Imagine that youre placed in a field,
wearing a blindfold, and youre given a little bag of tools. Youre told that your job is to
run around this field, blindfolded. That is how you are supposed to live life. And so you
do what you are told. Now unbeknownst to you, in this field there are a number of
widely-spaced, fairly deep holes. You dont know that at first--youre naive. So you start
running around and sooner or later you fall into this large hole. You feel around and sure
enough you cant climb out and there are no escape routes you can find. Probably what
you would do in such a predicament is take the bag of tools you were given and see what
is in there: maybe there is something you can use to get out of the hole. Now suppose that
there is a tool in that bag but what youve been given is a shovel. Its seemingly all
youve got. So you dutifully start digging, but pretty soon you notice that youre not out
of the hole. So you try digging faster, and faster. But youre still in the hole. So you try
big shovel fulls, or little ones, or throwing the dirt far away or not. But still you are in the
hole. All this effort and all this work and oddly enough the hole has just gotten bigger and
bigger and bigger. Hasnt it? So you come in to see me thinking maybe he has a really
huge shovel--a gold-plated steam shovel. Well, I dont. And even if I did I wouldnt use
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it because digging is not a way out of the hole--digging is what makes holes. So maybe
the whole agenda is hopeless--you cant dig your way out, that just digs you in.
This metaphor is extremely flexible. It can be used to deal with many beginning issues. In
the interaction with the client, the therapist can build out the metaphor to address these
specific issues that the client raises or that you think are there. It is also useful to try to
integrate these responses into the ongoing metaphor, as demonstrated by some of the
following scripting:

1. Maybe I should just put up with it.
Youve tried other things. Youve tried to tolerate living in a hole. You sit down and
twiddle your thumbs and wait for something else to happen. But that doesnt work and
besides, its just no fun living your life in a hole. So when you say put up with it or
give up what I hear is secretly staying with the same agenda (digging your way out) but
no longer trying because it doesnt work. Im suggesting something else. Im suggesting
changing the agenda.

2. I need to understand my past.
Another tendency you might have would be to try and figure out how you got in the
hole; you might tell yourself, Gee, I went to the left, and over a little hill, and then I fell
in. And of course that is literally true; you are in this hole because you walked exactly
that way. Your exact history brought you here. But notice something else. Knowing every
step you took does nothing to get you out. And besides--remember you are blindfolded--
even if you had not done exactly that, and youd gone somewhere else instead. In this
metaphor, you might have fallen into another hole anyway, because there are lots of holes
to be found. So you found anxiety, someone else found drug abuse, someone else found
bad relationships, someone else found depression. Now Im not saying your past is
unimportant, and Im not saying we wont work on issues that have to do with the past.
The past is important but not because figuring it out lets you escape emotional pain. It is
only the past as it shows up here and now that we need to work on--not the dead past.
And it will show up in the context of you moving on with your life. When it does, we will
work on it. But dealing with the past isnt a way out of the hole.

3. Am I responsible for these problems?
Note that in this metaphor, you are responsible. Responsibility is recognizing the
relationship between what we do and what we get. Did you know that originally the word
responsible was written response able? To be responsible is simply to be able to
respond. So, yes, you are able to respond. And yes your actions put you in the hole and
your actions can take you out. Response-ability is acknowledging you are able to respond
and were we to do so, the outcome would be different. If you try to avoid responsibility
there is a painful cost: if you cannot respond, then truly nothing will ever work. But Im
saying digging is hopeless, not you are hopeless. So dont back up from responsibility--if
you have an ability to respond, then there are things you can do. Your life can work.

4. Should I blame myself?
Blame is what we do when we are trying to motivate people to do something--to change
or to do the right thing. But you look plenty motivated to me. Do you need more? Do you
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need to buy Im at fault? Blame is like standing at the edge of the hole and throwing
dirt on top of the persons head and saying Dig out of here! Dig out of here! The
problem with blame in this situation is that it is useless. If the guy in the hole has dirt
thrown down on his head it wont make it any easier to get out of the hole. That doesnt
help. When your mind starts blaming you, does buying blaming thoughts strengthen you
or weaken you? What does your experience tell you? So if you buy blame from your
mind, go ahead, but then be response-able about that. If you buy into that you will be
doing something that your experience tells you doesnt work.

5. What is the way out?
I dont know, but lets start with what isnt working. Look, if you still have an agenda
that says dig until you die, what would happen if you were actually given a way out?
Suppose someone put a metal ladder in there. If you dont first let go of digging as the
agenda youd just try to dig with it. And ladders are lousy shovels--if you want a shovel
youve got a perfectly good one already.

6. The need to give up first.
Until you let go of the shovel you have no room to do anything else. Your hands cant
really grab anything else until that shovel is out of your hand. You have to let it go. Let it
go.

7. A leap of faith.
Notice you cant know if you have any options until you let go of the shovel, so this is a
leap of faith. It is letting go of something, not knowing if there is anything else. In this
metaphor you are blindfolded after all--youll only know what else is there by touch and
you can only touch something else when the shovel is out of your hands. Your biggest
ally here is your own pain. That is your friend and ally here because it is only because
this isnt working that youd ever even think to do something as wacky as letting go of
the only tool you have.

8. The opportunity presented by suffering
You have a chance to learn something most people never will--how to get out of holes.
You would never have had a reason to learn it if you hadnt fallen into this hole. Youd
just do the rational thing and muddle through--running around blindly your whole life,
perhaps. But if you can stay with this, you can learn something that will change your life.
Youll learn how to disentangle yourself from your own mind. If you could have gotten
away with it --more or less--youd never have done that.

Homework
Finally, ask one person to volunteer to give examples of what types of things they've
done that are digging - things that may have looked like they'd help, but really just got
them deeper in the hole. Try to get at least 2-3 clear, operational examples. This is set-up
for handing out the homework for the assignment group the next day. Then, hand out the
assignment, where they're all asked to come up with 3 things they do that are digging.
Ask someone to read the assignment out loud and explain that they each need to have it
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done by tomorrow morning, regardless of whether they come to assignment group or not.
This process takes 5+ minutes.
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Homework Assignment

As we discussed today, we all sometimes make the mistake of trying to dig our way out
of a hole. Of course, this only gets us deeper and deeper in the hole. For Wednesday, Id
like you to work on identifying some of the things that you do that get you more and
more STUCK!

In preparation for next weeks group, please identify 3 things that you do that are
digging in your life things that you do that are meant to solve your problems but just
seem to work in the short term, dont work at all, or maybe even make things worse.
Anything that keeps you stuck would be considered digging.

Digging #1:

Digging #2:

Digging #3:

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Wednesday Quiet Reflection

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Review of Radical Hope
For those who missed the Monday education group and didn't hear the hole metaphor, or
for those who slept through it the first time, ask a patient volunteer to review the basic
premise of the metaphor for the group.

Review of Control/Digging Strategies
Ask group participants to come up with a comprehensive list of the things that they
identified as digging for their homework the previous day. [The basic query is: what are
all the things that you've tried to do to deal with your difficult thoughts, feelings, and
memories over the years?] This can be a huge laundry list containing:

Drugs
Alcohol
Oversleeping
Overeating
Isolating
Angry outbursts
Sex
Lying
Manipulating
Geographical moves
Using people
Overworking
Overanalyzed things
And a million other things that they may come up with individually

Point out that all of the things on this list are also the things we mean when we talk about
someone as a "dry drunk." Someone who is engaging in behaviors similar to what an
addict does, even though they're not actively using.

Avoidance
Ask the group what all of the things on the list have in common. Usually someone can
come up with some phrase like, "avoidance," or "escape," or "they're all things that you
do, but that don't ever do anything to really fix the underlying problem." Basically you
want to get to the point where you can label these general behaviors escape or avoidance.

Ask if anyone thinks this is sort of strange. "You're smart people, you've worked hard,
you tried hard. If you put as much effort into anything else as you have at trying to avoid
all this stuff, then you would have been really successful at anything you were trying to
do. And sometimes it even seems like it makes things better in the short term.
Yet here you are again. Does anyone smell a rat here?" Let people comment and see if
they can get in contact with the futility of the avoidance strategy.
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"And has anyone in here ever had the experience that if though it doesn't seem that it
should work that way, that sometimes the MORE you struggle, the more difficult things
get?" Usually about a quarter of the group can relate to this.

"So, let's start with where you are. Do you feel stuck? Does anyone in here feel like
they're in that hole we talked about on Monday, right now? Ok, well good - then the first
thing we need to do is to put down the shovel. And the good thing is that now we've
come up with a long list of things that the folks in this room use as a shovel. So, if you
can at least STOP doing those things, then you're making progress. Then at least you
won't be making the hole any deeper."

The Quicksand Metaphor
We have a problem here and that is that your mind tells you to do what doesnt work,
because it cant see anything else to do. It would be like if you were caught in quicksand.
Naturally, youd try to get out. But almost everything youve learned about how to get
out will cause problems in quicksand. If you try to walk, jump, climb, or run, you just
sink in deeper because you end up trying to push down on the sand. If you struggle,
wiggle, push with your hands, or crawl, you sink in deeper. Often, as people sink, they
get panicky and start flailing about, and down they go. In quicksand, the only thing to do
is to create as much surface area as possible, to lay out on the quicksand, getting
everything you have in full contact with it. Its like that. We need to get everything you
have in full contact with what youve been struggling with, but without more struggle.
That will be hard - not hard meaning effortful, but hard meaning tricky. Its tricky
because your mind tells you to do what doesnt work, because it cant see anything else
to do. And it has learned this so well that you cant just tell it to stop and expect that it
will.

Next, present the Driving with the Rearview Mirror metaphor. The point of this metaphor
is to take their hands off the thing they've been using to try to steer their life (the shovel,
avoidance, the rearview mirror) and begin to focus on what might actually work:

Driving the Car with the Rear-View Mirror Metaphor
Its as if you got into your car and took off down the highway. Unfortunately, whoever
taught you how to drive told you that the way to steer the car is by holding onto and
turning the rear-view mirror. Now, you might be able to go a long way once you start
down the road without anything much happening, depending on whether the road youre
on is straight, or whether there is much oncoming traffic, and so on. Eventually,
however, the car is going to crash. But the what you do is dust yourself off, start the car
again, grab the rear-view mirror, and start driving again. But you keep crashing! The
problem isnt with the car, or with the driver; the problem is that you cant steer a car
with the rear-view mirror. This kind of therapy is about teaching you to put your hands
on the steering wheel instead of the rear-view mirror. This therapy isnt about where you
have been so much as where you are going and how to get there.

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If there is still time, or if this metaphor fits better on a given day than the Driving with
the Rearview Mirror, present the Feedback Screech Metaphor:

The Feedback Screech Metaphor
You know that horrible feedback screech that a public address system sometimes makes?
It happens when a microphone is positioned too close to a speaker. Then, when a person
on stage makes the least little noise, it goes into the microphone, the sound comes out of
the speakers amplified and then back into the mic, a little bit louder than it was the first
time it went in, and at the speed of sound and electricity, it gets louder and louder until, in
split seconds, its unbearably loud. Your struggles with your thoughts and emotions are
like being caught in the middle of a feedback screech. So what do you do? You do what
anyone would. You try to live your life [whispering] very quietly, always whispering,
always tip-toeing around. You cant really live without making noise. But notice that in
this metaphor, it isnt how much noise you make that is the problem. Its the amplifier
thats the problem. Our job in here is not to help you live your life quietly, free of all
emotional discomfort and disturbing thoughts. Our job is to find the amplifier and to take
it out of the loop.

Finally, talk to the group about where we're going from here. Tell them that the work of
therapy from now on will be on identifying their steering wheel and learning how to take
control of their lives, rather than trying so hard to control their emotions. But this isn't
something that we can directly instruct them how to do:

The Baseball Metaphor
There is something you can do in this situation, but I cant just lay it out logically. Even if
I did, it wouldnt help. It is something like hitting a baseball. It doesnt help to have too
much analysis about how to do it. Yogi Berra said that the best thing to do was dont
think, just hit. If you ever went to the plate thinking a lot about how to hold the bat, the
right position to take, where your wrists should break, and so on, chances are you didnt
hit the ball very well. Youd be off in the ozone thinking while the ball went past. Your
hand, arms, and eyes know a lot more about how to hit than the verbal side of you does.
This is like that. There is a skill to be learned, but it cant be learned through a whole lot
of literal, logical, linear language.

Journal Group Assignment
Hand out the Journal Group Assignment.

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1. Like in the quicksand metaphor, could you be willing to stop struggling with your
own thoughts, feelings, memories, bodily sensations, etc. and instead just stay
still, and be in contact with them? What reactions do you have to that idea?

2. What would you have to do in order to stop struggling? Imagine yourself actually
doing this. What would it look like? What would you be doing instead?

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Friday Quiet Reflection

Imagine that the course of your life depends on you steering a car down a road in the
direction of whats important to you. And so at the beginning of this process, you get into
your car and take off down the highway. Unfortunately, whoever taught you how to
drive told you that the way to steer the car is by holding onto and turning the rear-view
mirror.

Now, you might be able to go a long way once you start down the road without anything
much happening, depending on whether the road youre on is straight, or whether there is
much oncoming traffic, and so on. Eventually, however, the car is going to crash. So,
what you do is dust yourself off, start the car again, grab the rear-view mirror, and start
driving again. But you keep crashing!

The problem isnt with the car, or with the driver; the problem is that you cant steer a car
with the rear-view mirror! What were working on here is about teaching you to put your
hands on the steering wheel instead of the rear-view mirror. Our focus is less on where
you have been, and more on where you are going and how to get there.

Reflection Question: Have I been steering my life using the steering wheel, or the
rearview mirror? What would I need to do to plant my hands more firmly on the
steering wheel?

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Week Two: Control vs. Willingness


Willingness Quotes

If nothing changes, nothing changes.
Ernie Larson

If you do what you always did, youll get what you always got.
Moms Mabley

Reflection Question:
How can you stop doing what doesnt work AND are you willing to
try something different?

Requires ACCEPTANCE and WILLINGNESS and COURAGE

COURAGE (literally, to have heart): the attitude of facing and dealing with
anything recognized as difficult or painful, instead of withdrawing from it

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Monday Curriculum

Acceptance
First, read the following paragraph from the Big Book:

And acceptance is the answer to all my problems today. When I am disturbed, it
is because I find some person, place, thing, or situationsome fact of my life
unacceptable to me, and I can find no serenity until I accept that person, place,
thing, or situation as being exactly the way it is supposed to be at this moment.
Nothing, absolutely nothing happens in Gods world by mistake. Until I could
accept my [addiction], I could not stay sober; unless I accept life completely on
lifes terms, I cannot be happy. I need to concentrate not so much on what needs
to be changed in the world as on what needs to be changed in me and in my
attitudes. Doctor, Alcoholic, Addict. Alcoholics Anonymous (the Big
Book), p. 449

Ask the group to reflect on what they connected with in this statement. Connect this back
to principles of ACT and how they have struggled against acceptance in the past. Relate
this explicitly to suffering they have experienced in their lives and attempts to control
internal events.

Review of Creative Hopelessness
Review the main points from the curriculum of Creative Hopelessness. Have the group
identify with the futility of continuing to try things that dont work (Doing the same
thing and expecting different results.). Relate this to the problem people typically have
with Step One in AA Twelve Steps Admit the powerlessness one has over alcohol and
that ones life has become unmanageable.

Powerlessness
Facilitate group discussion on topic of powerlessness. Discuss why people typically
struggle against powerlessness. Feeling out of control over the events in ones life is in
contrast to what we have been socialized to and gives the sense of vulnerability. Identify
what people are typically making attempts to control (for example: other peoples
behavior, internal events). Discuss success of these attempts and workability of such
attempts. This discussion is helpful for setting up the idea of using the Serenity Prayer to
identify what is under ones control and what one is powerless over. Ask a group
participant to say the serenity prayer out loud to the group.

Control As The Problem
Write a chart on a dry erase board with two headings: What You Are Powerless Over
and What you Have Control Over (See page 20). Ask for examples from group
participants about control strategies. This includes a long list of specific external and
internal events, such as other people, negative consequences, cravings to use and
injustice. The final chart should reflect the idea that the only thing anyone has control
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over is his or her values, attitudes and actions in this moment (make explicit this does not
include events in the past or future).

What You Are Powerless Over
(No Choice)
What You Have Control Over
(Choice)
Other peoples thoughts, feelings, attitudes, and
actions in the past, present, and future
Your own thoughts and feelings in the past,
present, and future
Your values, attitudes and actions in the past and
Future

Your values, attitudes and actions right this
moment

Pose the question to the group: What if it is the case that control and/or avoidance is the
problem not the solution at least in some cases? Facilitate group discussion to
differentiate when control and avoidance does work (for example, running from a tiger or
getting out of a house when there is a fire) versus when it does not work (for example,
trying to control other people, using substances to block out negative memories).

Next, ask for a volunteer from the group to participate in acting out a metaphor with the
group leaders, the Tug-a-War-with-a-Monster Demonstration.

Tug of War With A Monster
The situation is like being in a tug-of-war with a monster. It is big, ugly, and very
strong. In between you and the monster is a pit, and so far as you can tell it is bottomless.
If you lose this tug-of-war you will fall into this pit and will be destroyed. So you pull
and pull, but the harder you pull it seems the harder the monster pulls, and it seems you
edge closer and closer to the pit. The hardest thing to see is that our job here is not to win
the tug-of-war. ..... Our job is to drop the rope.

Facilitate group discussion regarding the alternative to struggling with the monster and
attempts at control, which is to let go of the rope (struggle). Allow group members to
come to the understanding that the monster will remain on the other side of the pit,
remaining scary and ugly. However, the advantage to dropping the rope and looking at
the monster for what he is is that the patient has the freedom to move around. This
allows the patient to see the monster from different vantage points and frees he or she up
for new possibilities and actions. The patient has to be willing to accept the discomfort
of seeing the monster across the pit before he or she can gain this freedom.

Clean Versus Dirty Discomfort
Distinguish between clean and dirty discomfort. The discomfort that life just dishes
up--that comes and goes as a result of just living ones life--that is clean discomfort.
Sometimes it will be high, or it will be low, because of individual learning histories and
the environmental circumstances in which patients find themselves. The clean
discomfort is what cant be decreased by trying to control it. Dirty discomfort, on the
other hand, is emotional discomfort and disturbing thoughts actually created by your
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effort to control feelings. As a result of running away, whole new sets of bad feelings
have shown up. Allow patients to connect with the idea that this process is a part of why
they are in treatment. That extra discomfort--discomfort over discomfort--is called dirty
discomfort. Once willingness is high, and control is low, it kind of falls out of the
picture, leaving only the clean kind. Discuss the fact that one can never predict the
level of discomfort he or she will have left in any given situation once only clean
discomfort is there. Be very clear with group members that the idea is not that discomfort
will go down, but that if efforts to manipulate discomfort is let go of, then over time it
will assume the level that is dictated by patients actual history and experience.

What Acceptance is NOT
Patients often hear acceptance and think resignation. Allow patients to discuss their
thoughts on the word acceptance and distinguish between active acceptance and passive
resignation. Acceptance is not the same as giving up. Acceptance is an active process
of feeling what you feel, thinking what you think, remembering what you remember. It
involves the willingness to let your experience be exactly what it is. Use AA slogan of
accepting life on lifes terms to illustrate this idea, which many patients often connect
to.

Homework
Hand out homework assignment and explain rationale.

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Homework Assignment

Control and Willingness

1. Identify a situation, person, or event that you have had difficulty accepting.

2. What thoughts do you have about this situation, person, or event?

3. What emotional reactions come up for you when you think about this situation,
person, or event?

4. Who would you be IF you were able to accept this situation, person, or event exactly
as it is? How would you be different? How would your life be different?

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HEAVEN AND HELL

Theres another story that you may have read that has to do with what we call
heaven and hell, life and death, good and bad. Its a story about how those things dont
really exist except as a creation of our own minds. It goes like this: A big burly samurai
comes to the wise man and says, Tell me the nature of heaven and hell. And the roshi
looks him in the face and says: Why should I tell a scruffy, disgusting, miserable slob
like you? The samurai starts to get purple in the face, his hair starts to stand up, but the
roshi wont stop. He keeps saying, A miserable worm like you, do you think I should
tell you anything? Consumed by rage, the samurai draws his sword and hes just about
to cut off the head of the roshi. The roshi says, Thats hell. The samurai, who is in fact
a sensitive person, instantly gets it, that he just created his own hell; he was deep in hell.
It was black and hot, filled with hatred, self-protection, anger, and resentment, so much
so that he was going to kill this man. Tears fill his eyes and he starts to cry and he puts
his palms together and the roshi says, Thats heaven.

There isnt any hell or heaven except for how we relate to our world. Hell is just
resistance to life. When you want to say no to the situation youre in, its fine to say no,
but when you build up a big case to the point where youre so convinced that you would
draw your sword and cut off someones head, that kind of resistance to life is hell.

In the way we practice, we dont say, Hell is bad and heaven is good or Get rid
of hell and just seek heaven, but we encourage ourselves to develop an open heart and
an open mind to heaven, to hell, to everything. Why? Because only then can be realize
that no matter what comes along, were always standing at the center of the work in the
middle of sacred space, and everything that comes into that circle and exists with us there
has come to teach us what we need to know.

Lifes work is to wake up, to let the things that enter into the circle wake you up
rather than put you to sleep. The only way to do this is to open, be curious, and develop
some sense of sympathy for everything that comes along, to get to know its nature and let
it teach you what it will. Its going to stick around until you learn your lesson at any rate.
You can leave your marriage, you can quit your job, you can only go where people are
going to praise you, you can manipulate your world until youre blue in the face to try to
make it always smooth, but the same old demons will always come up until finally you
have learned your lesson, the lesson they came to teach you. Then those same demons
will appear as friendly, warmhearted companions on the path.

Pema Chodron
The Wisdom of No Escape and the Path of Loving-kindness
pp. 31-32
24


Review of Control as the Problem
First, ask patients for reflections or thoughts on Wednesday Quiet Reflection. Ask if
anyone can connect the Quiet Reflection to the weeks theme of Willingness. Review
with patients the rationale for Control as the Problem. Ask group members to remember
some of the main control strategies they had identified in Monday group and the main
theme that connects them control. Review table created on Monday (Powerlessness v.
Control). Finally briefly summarize the distinction between clean and dirty discomfort.

The Cost of Unwillingness
As patients if they can identify any costs of being unwilling to experience their thoughts
and feelings. Generate a list of negative consequences of experiential avoidance. This
may include a long list of things such as social isolation, poor relationships, loss of
employment, etc. Keep in mind ten values areas while helping patients think of
consequences. Relate some basic ideas to group such as: If youre not willing to have it,
youre stuck with it.

Metaphors
Two Scales
Group leaders physically create the two scales with paper anchors (Likert-scale numbers
written on large pieces of paper) in the middle of the group of patients. Ask for a
volunteer to physically move one group leader up and down on the scale while the other
group leader explains the metaphor. Have them both stand with the Discomfort scale in
front of them and the Willingness Scale behind them. Explain the numbers are anchors
on are two scales, like the volume. It can go from 0 to 10. In the posture youre in, what
brought you in here, was this: This discomfort is too high. Its way up here and I want
it down here and I want you, the therapist, to help me do that, please. In other words you
have been trying to pull the pointer down on this scale (The group participant pulls the
group leader down to 0, while the group leader resists against him or her). But now
theres also another scale. Its been hidden. It is hard to see. This other scale can also go
from 0 to 10. [move the other hand up and down behind your head so you cant see it]
What we have been doing is gradually preparing the way so that we can see this other
scale. Weve been bringing it around to look at it. [move the other hand around in front]
It is really the more important of the two, because it is this one that makes the difference
and it is the only one that you can control. This second scale is called Willingness. It
refers to how open you are to experiencing your own experience when you experience it--
without trying to manipulate it, avoid it, escape it, change it, and so on. When Discomfort
is up here at 10 (Group leader stands at 10 anchor), and youre trying hard to control this
discomfort, make it go down, make it go away (Have group participant try to move other
leader down to 0 on Willingness Scale), then youre unwilling to feel this discomfort. In
other words, the Willingness scale is down at 0. But that is a terrible combination. Its
like a ratchet or something. You know how a ratchet wrench works? When you have a
ratchet set one way no matter how you turn the handle on the wrench it can only tighten
25
the bolt (Act this out dramatically on the scales with group leaders and patient). Its like
that. When Discomfort is high and Willingness is low, the ratchet is in and Discomfort
cant go down. Thats because if you are really, really unwilling to have Discomfort then
it is something to be anxious about. Its as if when Discomfort is high, and Willingness
drops down, the discomfort kind of locks into place. You turn the ratchet and no matter
what you do with that tool, it drives it in tighter. So, what we need to do in this therapy is
shift our focus from the Discomfort scale to the Willingness scale. Youve been trying to
control Mr. Discomfort for a long time, and it just doesnt work. Its not that you werent
clever enough; it simply doesnt work. Instead of doing that we will turn our focus to the
Willingness scale. Unlike the Discomfort scale, which you cant move around at will, the
Willingness scale is something you can set anywhere. It is not a reaction--not a feeling or
a thought--it is a choice. Youve had it set low. You came in here with in set low--in fact
coming in here at all may initially have been a reflection of its low setting. What we need
to do is get it set high. If you do this, if you set Willingness high, I can guarantee you
what will happen to discomfort. Ill tell you exactly what will happen and you can hold
me to this as a solemn promise. If you stop trying to control discomfort, it will be low ...
or ... it will be high. I promise you! Swear. Hold me to it. And when it is low, it will be
low, until its not low and then it will be high. And when it is high it will be high until it
isnt high anymore. Then it will be low again. ... Im not teasing you. There just arent
good words for what it is like to have the Willingness scale set high--these strange words
are as close as I can get. I can say one thing for sure though and your experience says the
same thing--if you want to know for sure where the anxiety scale will be then there is
something you can do. Just set Willingness very, very low and sooner or later when
anxiety starts up the ratchet will lock in and you will have plenty of anxiety. It will be
very predictable. All in the name of getting it low. If you move the Willingness scale up
then anxiety is free to move. Sometimes it will be low, and sometimes it will be high, and
in both cases you will keep out of a useless and traumatic struggle that can only lead in
one direction.

Box Full of Stuff
Before beginning this metaphor, group leaders should gather a trash can and several small
objects. Suppose we had this trash can here. This [put various small items in the box,
some nice and some repulsive] is the content of you life. All your programming. Theres
some useful stuff in here. But theres also some old cigarette butts and trash in here. Now
lets say there are some things in here that are really yucky that you all have experienced,
like divorce, traumatic experiences and chronic pain . That would be like this [blow your
nose into a tissue and put it in the box]. Ask a group member what they would do with
the bad memories (e.g., Id think of something else.). When they give an answer that
fits with a control strategy, pick up another item and place it in the trash can identifying it
as that suppression method. Ask for more thoughts/feelings, placing them in the trash
can one by one. Do you see what is happening? This box is getting pretty full and notice
that at lot of these items have to do with that first yucky one. Notice that the first piece
isnt becoming less important--its becoming more and more important. Because your
programming doesnt work by subtraction so the more you try to subtract and item, the
more you add new items about the old. Now its true, some of this stuff you can shove
back in the corners and you can hardly see it anymore but its all in there. Stuffing things
26
back in the corners is seemingly a logical thing to do. We all do it. Problem is, since the
box is you, at some level the box knows, is in contact with, literally up next to all the bad
stuff youve stuffed in the corners. Now, if the stuff thats in the corners is really bad, its
really important that it not be seen. But that means that anything that is related to it cant
be seen, so it too has to go into the corner. So you have to avoid the situations that will
cause light to be cast into the corners. Gradually your life is getting more and more
squeezed. And note that doesnt really change your programming--it just adds to it.
Youre just stuffing another thing back into the corner. There becomes more and more
things you cant do. Can you see the cost? It must distort your life. Now the point is not
that you need to deliberately pull all the stuff out of the corner--the point is that healthy
living will naturally pull some things out of the corner and you have the choice either to
pull back to avoid it or let going forward with life open it up.

Homework
Hand out Journal Group Assignment.
27


Pain is inevitable; suffering is optional.

This week we are discussing how we tend to make our problems worse and
increase our suffering by refusing to accept reality as it is RIGHT NOW, and by our
unwillingness to experience whatever thoughts, feelings, memories, and physical
sensations accompany that reality. We call this dirty discomfort. In the story of the
Samurai, the wise man taught him how he had created his own hell by his
unwillingness to accept the situation for what it was.

1. How do you create dirty discomfort for yourself? How do you take a stressful
situation and make it worse? In your journal entry, please write about something that
happened today in which your unwillingness to accept the reality of the situation ended
up making things WORSE for you!

2. Next, write about a situation that happened today in which your willingness to
accept the situation as it was, and your willingness to own your feelings, thoughts, and
reactions to the situation, brought you at least a little taste of peacefulness and calm

28


A. CONTROL AND AVOIDANCE
OR
B. ACCEPTANCE AND WILLINGNESS

Identify the approach (A or B) that best fits each of the statements below:

____ When negative experiences occur, the goal is to get rid of them or get them
under control so that they hurt less.

____ The attempt to control or get rid of negative experiences creates problems; the
goal is to let them be there, and they will change as a natural part of living.

____ The way to understand negative experiences is to understand why I am having
them, and then use that knowledge to eliminate them.

____ The way to understand negative experiences is to notice that they are present
without necessarily analyzing them or judging them.

29
Week Three: Defusion/Deliterization


Defusion Reflection

"Do we control what we think?"

Facilitate debate of this topic for 10 minutes

Reflection Question:
What would it mean if we do control our thoughts and what would it mean if we don't
actually control our thoughts?
30

Monday Curriculum

Review of Control as the Problem and Willingness:
First, ask patients for reflections or thoughts on Monday Quiet Reflection. Briefly review
the concepts and rationale for Control as the Problem and Willingness.

Pop Quiz
Hand out the pop quiz below. Group leaders typically use irreverent humor to indicate
the importance of getting each question right by stating the quiz will be graded, or
saying that their grade will determine their progress or be judged harshly.
Note: These comments should be used in a light and playful manner, as some
patients may fear unsuccessful completion in the treatment program. If group
leaders note distress or fear in patients when this is stated, misconceptions should
quickly be corrected. If after several attempts at using this style, it appears the
patients do not respond well, other approaches to introducing psychological
flexibility are encouraged.

Allow group approximately ten minutes to complete the quiz, then facilitate discussion of
answers one by one. Group leaders should play the devils advocate on both sides of
each question by using the key discussion points and exercises listed below each
question. The point of this group exercise is not to decide on an answer to each question,
but to encourage flexibility in thought by recognizing there may be no right answer.

RECOVERY POP-QUIZ
Acceptance and Willingness, Part II

1. I think, therefore I am T F

Discussion Points:
Each individual has a learning history that includes being taught that thinking is
equivalent to being. Identify instances where this idea can be true (How do we
know if we are living if we dont have a consciousness?) and also instances where
this is untrue (e.g. comatose states).

Defusion exercises:
Encourage patient to try replacing the thought I am depressed with. I am
having the thought that I am depressed.
Put thought on the board and stand back to look at it. What does it mean to be
able to "observe" one's own thought? How does this observer perspective change
ones contact with the thought? Can one observe a thought and still be a living,
breathing human being at the same time?

2. If this program teaches me anything, T F
its that avoidance is always unhealthy
31

Discussion Points:
Rigid adherence to rules has typically not worked for people in the past.
Facilitate discussion on instances where rule governed behavior has gotten them
into problematic patterns of living.
Stress the functional/contextual nature of avoidance, reminding patients examples
from previous week in Willingness.
There are some things we simply cannot avoid, such as internal states (thoughts).
Again, stress the need to determine the workability of avoidance, particularly with
internal states. Identify times where group members made efforts to avoid painful
thoughts or memories by using substances or other methods and this effort caused
increased psychological distress.

3. The more I try to stop a thought, the
stronger the thought becomes T F

Defusion Exercise:
Instruct patients to not think of chocolate cake for 30 seconds. Suppose I tell
you right now, I dont want you to think about something. Im going to tell you
real soon. And when I do dont think it even for a second. Here it comes.
Remember, dont think of it. Dont think of ....Warm chocolate cake! You know
how it smells when it first comes out of the oven...Dont think of it! The taste of
the chocolate icing when you bite into the first warm piece ...Dont think of it! As
the warm, moist piece crumbles and crumbs fall to the plate...Dont think of it!
Its very important, dont think about any of this!

Discussion Points:
Facilitate discussion after the exercise on the futility of thought suppression
following this experience.
Ask patient how often they thought of chocolate cake prior to this exercise and
compare this with how many times an intrusion of chocolate cake occurred in the
past 30 seconds.
Highlight how many associated thoughts come up when one tries to suppress
thoughts (e.g., thoughts of milk, birthdays, etc.) as well as bodily sensations (e.g.,
stomach growling, salivation, etc). Relate this to cravings and related thoughts,
sensations, memories, etc.

4. In recovery, behaviors must change T F
but my thoughts and feelings are OK
the way they are.

Defucsion Exercise:
Soldiers on Parade: If you are willing, Id like to do a closed eyes exercise to
show how quickly thoughts can pull us away from experience when we buy them.
All Im going to ask you to do is think whatever thoughts you think and to allow
them to slow, one thought after another. The purpose of the exercise is to notice
32
when theres a shift from looking at your thoughts to looking from your thoughts.
You will know that has happened when the parade stops, or you are down in the
parade, or the exercise has disappeared. Im going to ask you to imagine that
there are little people, soldiers, marching out of your left ear down in front of ou
in a parade. You are up on the reviewing stand, watching the parade go by.
Each soldier is carrying a sign, and each thought you have is a sentence written
on one of these signs. Some people have a hard time putting thoughts into words,
and they see thoughts as images. If that applies to you, put each image on a sign
being carried by a soldier. Simply watch the parade go by without having it stop
and without your jumping down into the parade. You are just supposed to let it
flow. It is very unlikely that you will be able to do this without interruption. And
this is the key part of this exercise. At some point, you will have the sense that te
parade has stopped, or that you have lost the being point of the exercise, or that
you are down in the parade instead of being on the reviewing stand. When that
happens, I would like you to back up a few seconds and see whether you can
catch what your thoughts on the placards again, until the parade stops a second
time, and so on. The main thing is to notice when it stops for any reason and see
whether you can catch what happened right before it stopped. If the parade never
gets going at all and you start thinking, Its not working, or Im not doing it
right, then let that thought be written on a placard and send it down into the
parade.

Discussion Points:
Adopting a stance of acceptance and mindfulness of thoughts allows use to slow
down habitual ways of responding to triggers and choose our behaviors more
carefully.

Homework Assignment
Hand out homework assignment and answer any questions patients have about
completing it.

33

Homework Assignment

Reacting to Uncomfortable Emotions:

AVOIDANCE
Stuffing It------------------------------------------------------------------------Acting It Out

Responding to Uncomfortable Emotions:

EXPERIENCING IT
"Sitting with it"

List two emotions that you wish you could get rid of.
________________________________________________________________________
________________________________________________________________________

How have you tried to avoid/get rid of each of the two emotions you listed?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

How has trying to get rid of these emotions gotten in the way of living a valued life?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
34
Week Three: Defusion/Deliterizaton


The Squiggly Line Exercise

On the board, make a few non-descript squiggles with an ink marker.
Ask patients what they see
Notice the tendency to read into, project, or otherwise interpret something when nothing
is actually there but ink on a board.
Tell patients that all that is there is a bunch of squiggly lines made out of ink.

Now write up on the board the words: "You are all wimps"
Ask patients what they seeAsk what feelings and thoughts come up
Remind patients that all that is on the board is more squiggly lines made out of ink.

Now just change the letters slightly to make the words read: "You are all winners"
Ask patients what they now seeAsk what feelings and thoughts come up now.
Remind patients that all that is on the board is differently shaped squiggly line made out
of ink.

The message of this exercise is that our thoughts are like squiggly linesthey come and
go and change all the time, sometimes they seem to mean something, sometimes not. Our
job is simply to notice them and notice if we are feeding into them and remind ourselves:
that is just a thought (that is just a squiggly line this is just ink).

35


Review of Control as the Problem and Willingness:
First, ask patients for reflections or thoughts on Wednesday Quiet Reflection. Review
concepts from Monday curriculum. Relate psychological flexibility taught in Monday
curriculum to Wednesday Quiet Reflection. Discuss idea of thoughts being ink/words
that humans attach meaning to. Have patient been able to notice thoughts from this
detached perspective over the course of the day?

Identification of Thoughts
Group leaders should come prepared with paper, pens and a trash can.

Hand out a sheet of paper to group members and ask them to write down a commonly
occurring uncomfortable thought. Reinforce to patient this should be a bad thought, or
a negative thought they have been trying hard to get rid of. When everyone has identified
a thought, ask patients to crumple up their papers. One group leader will collect their
bad thoughts in the Bad Thought Wastebasket.

The co-facilitator will sit in a chair in the middle of the circle for the defusion exercise.

Getting Rid of the Bad Thoughts
We are going to practice getting rid of bad thoughts. We are going to practice using your
thoughts. The group leaders job is to keep all these thoughts from hitting him.

Group leader will throw the balled up paper at him, slowly, then faster, varying the
throws. The co-facilitator tries urgently to block all the paper, using a lot of energy and
activity.

Ask participants what they noticed about this exercise. Some questions to get them
thinking about the frequency and intensity of thoughts are:
Did you notice how some thoughts come in slow and easy, and others are fast
and racing?
Did the pace or strength change according to how much the group leader
struggled not to have them?

Facilitate discussion about the utility of thought suppression in this exercise.
So how did the group leader do?
How hard was he working?
How much energy was he using to block out all those thoughts?
How successful was he?
How much energy did he have for doing anything else?

Meditation-Getting Rid of the Bad Thoughts

36
I want you all now to practice this like the group leader did, except well use real
thoughts instead of paper. I want everyone to sit in a comfortable, upright position,
keeping your eyes OPEN. I want you to remember the BAD thought you wrote down and
hold it in your mind. When youve got that thought in your mind, please raise your hand.
Now, what I want you to do is concentrate very hard, keep your eyes open, and for the
next two minutes, I want you to get rid of that thought. Go ahead.

Facilitate discussion of their own experiences with attempts at thought suppression.
How did you do?
How much mental energy did you use to block out all those thoughts?
How successful were you?
How much energy did you have to do other things?

Holding on to Good Thoughts
Hand out a sheet of paper to group members and ask them to write down a happy,
pleasant, positive thought. Reinforce to patient this should be a good thought, or a
thought they have been really wish to have more often. When everyone has identified a
thought, ask patients to crumple up their papers. One group leader will collect their
good thoughts in the Good Thought Wastebasket.

Now we are going to practice holding onto pleasant thoughts. So to begin, I want
everyone to ball up their piece of paper. Now I want everyone to throw their 'good
thought into this wastebasket.

The co-facilitator will sit in a chair in the middle of the circle for the defusion exercise.

We are now going to practice holding onto good thoughts. We are going to practice with
your thoughts. The group leaders job this time is to catch and hold onto all of these
thoughts and not to drop any of them.

The group leader will throw the balled up paper at him, slowly, then faster, varying the
throws. The co-facilitator will try urgently to catch and hold onto all the paper, using
much energy.

Ask participants what they noticed about this exercise. Some questions to get them
thinking about the frequency and intensity of thoughts are:
Did you notice how some thoughts come in slow and easy, and others are fast
and racing?

Facilitate discussion about the futility of trying to increase positive thoughts.
So how did the group leader do?
How much energy did he have to do other things?

37

Meditation-Holding on to the Good
keeping your eyes OPEN. I want you to remember the thought you wrote down and hold
it in your mind. When youve got that thought in your mind, please raise your hand.
Now, what I want you to do, is concentrate very hard, keep your eyes open, and for the
next two minutes, I want you to keep that thought in your head. Don't allow the thought
to leave your mind, even for a second, or allow any other thought in. Go ahead.

Facilitate discussion of their own experiences with trying to increase positive thoughts.
How did you do?

Having the Thoughts
The co-facilitator will sit in chair in middle of the room again. This time, he is instructed
to simply have the thoughts. Paper is thrown at him in a similar way, but this time, the
group leader does not attempt to block them away. He lets them hit him and bounce off.

Ask participants what they noticed about this exercise, noting differences between the
first two exercises is particularly important. Allow patients to identify similarities and
differences on their own before using leading questions.
So how did the group leader do this time?
Did the frequency of intensity of thoughts change from the other two exercises?
How much energy did James have to do other things?

Experiential Exercise: Clouds in the Sky
keeping your eyes OPEN. I want you to remember the thought you wrote down and hold
it in your mind. When youve got that thought in your mind, please raise your hand.
Now, what I want you to do, is follow along with the meditation.

Do you remember how as a kid it was fun to lie on the ground and look up at the clouds
moving across the sky? Sometimes you saw shapes in the clouds, and maybe you even
saw pictures or things happening. Sometimes the sky is empty of clouds, but usually there
are at least some clouds. Often, the sky is filled with big clouds, sometimes, its overcast,
dark, and rainy. Sometimes the clouds dont appear to move much at all, and sometimes,
when its windy, the clouds move very quickly across the sky.

Watching our own thoughts is like looking at clouds move across the sky.
38

I want you now to picture the thought that you wrote down and imagine as if you are
actually seeing the letters of the words to that thought appear in your mind like they are
clouds in the sky. Make no effort to get rid of the letters. Just look at them. Notice their
color, shape, size, movement. What happens when you make no attempt to get rid of the
letters and words? What would it be like to try to reach into the sky and push a cloud
more quickly through the sky. Would it work? As you allow yourself to have the thought,
now see if any other thoughts float through your mind. What is it like to not fight with
them?

Facilitate discussion of their own experiences during the exercise.
How did you do?

Hand out journal group assignment and answer questions patient may have about
completing it.

39


Take Your Keys With You

For your journal group assignment this week, identify several different emotions,
thoughts, memories, or sensations you have been struggling with lately. These can be
about trauma, substance abuse, or both.

Examples include:

I dont think I can ever stop using.
I will never make up all my years of using to my family.
Tightness in chest, restlessness, or other sensations of anxiety and cravings
Memories of your trauma

Write your own examples here:

1. _______________________________________________________

2.________________________________________________________

3. _______________________________________________________

Now, take 3 small pieces of paper. Write your examples on the papers. Then, tape the
papers to 3 keys on your key ring. If you are willing, your homework is to carry your
keys, and your thoughts, memories, feelings, and sensations, with you for the next week.

Journal about several things during the next week about your experience carrying your
keys:

How much effort does it take to carry your keys with you?

What places can you go, or not go, depending on whether you have your keys
with you?

Does picking up your keys and carrying them with you prevent your from going
anywhere?
40


Cravings News Radio Metaphor

CRAVINGS NEWS RADIO (WSNR): This is Cravings News Radio, WSNR,
broadcasting inside your head, twenty hours a day, seven days a week. Wherever you
are, the signal will reach you. When you wake in the early hours, well be there to make
you aware of your craving to smoke, even before you get out of bed. Let us take over
and control your life. Cravings News Radio is compelling listening, and guess why? Its
the news station youve lived with for years, and now comes to you automatically, 24/7.
Pay attention! Cravings News Radio knows whats best for you and we want you to buy
our products. We advertise the products you fear most and want to avoid. So dont
forget that, and remember, if you should forget us and ACT without seeking permission,
then well broadcast all the louder. Remember, having cravings can be really awful, so
you should stay tuned to this station to know how to avoid them.

JUST SO RADIO (WJSR): Wake up! Cravings News Radio is just a station you can
tune in, or you can tune out! One thing is guaranteed though, whatever the time of day,
youll hear the same old stuff on WSNR. If thats been really helpful to you, then go
ahead, tune in and stay tuned. That would make sense. If not, then tune in more often to
Just So radio. We bring you the news of actual experience, in the moment, all live, all the
time. Actuality is out business! We give it to you straight as it is, not as your mind
says it is. In contact with the world outside and inside the skin, you can experience what
it is to be human, and its entirely free! We can guarantee that experiencing whats inside
the skin exactly as it is will never damage you, but it just might bring you joy. Just
So Radio brings you information about how things are, not how you fear they might be.
Just So Radio invites you to step forward and touch the world, just as it is, and to touch
your life, just as it is. We get louder the more you listen to us. So stay tuned. Give us a
fair trial, and if not convinced by your own experience (please dont take our word for it)
then WSNR 9 Cravings News Radio is still there on the dial.

41
Week Four: Values


Values Reflections
A little over ten years ago, as I was beginning my journey to integrating sacred
pampering and self-care into my life, I thought that having more joy and deep satisfaction
in my life was a matter of getting my priorities straight. A priority is something we
regard as more important than something else. But I discovered that having more joy in
my life didnt come about as a result of getting my priorities straight, but from having my
actions and behaviors consistent with what I said I valued. What you value is what you
consider significant and important.

An assessment of where, how, when, and with whom we invest our time and energy is an
accurate and telling barometer for where our priorities lie. We think that we act in
accordance with what we value. This is usually not the case. Most of us are usually
doing the oppositeour actions and behaviors are supporting something very different
from what we say is important to us. Unfortunately, this is the norm.

When your behavior is at odds with what you value, you experience anxiety,
dissatisfaction, spiritual constipation, and internal conflict. These are by-products of
the head-on collision of our behaviors and our values. What you value is a function of
your beliefs. Someones values, and thus his or her beliefs, show through a persons
actions, behaviors, and choices. In other words, demonstration is the vehicle through
which our values are revealed. When you say your values are one thing yet your actions
and behaviors demonstrate another, you undermine your power, integrity, and spiritual
energy.
Debrena Jackson Gandy, from All The Joy You Can Stand

You dont get to choose how youre going to die. Or when. You can only decide how
youre going to live. Now.
Joan Baez

He who is not courageous enough to take risks will accomplish nothing in life.
Muhammed Ali
42
Week Four: Values
Monday Curriculum

Group leaders will need a dry erase board, markers, 3x5 cards and pens for the group.

Review of ACT Rationale
Briefly review Control as the Problem, Willingness and Defusion concepts from previous
weeks for new members. Ask participants for thoughts on Monday Quiet Reflection,
relating this to themes discussed in previous weeks.

Write the quote If we dont decide where were going, were bound to end up where
were heading on the board to start off the lecture. Ask for the participants reactions to
this statement.

Values and Goals
Review the definitions of values and goals by asking the group to list the characteristics
of each & write them on the board.

Values a direction; a quality action.
1.) verbally construed global desired outcomes
2.) cannot be permanently achieved & maintained
3.) gives direction
4.) an action-valuing-not a private thought

Values are sometimes confused with feelings. Feelings & thoughts come & go; values
are bigger-give life meaning & direction. Goals are something you choose to work at;
they are time-oriented, specific, & measurable. They are proud to accomplish. Ask group
members how they view the relationship between values and goals.

Identification of a Value and Goal
Ask participants to identify a value and specific goals related to it. Discuss poor
examples of values/goals, such as the absence of something (e.g., not feeling anxiety).
Striving for the absence of something often is a poor guide and can lead to avoidance
with long term use.

Discussion question: Is recovery a goal or a value? Discuss differences between a value
and goal using recovery as an example.

Barriers
Ask participants what are some barriers that get in the way of living according to ones
values? Get specific examples from group members of practical barriers, such as
financial concerns, transportation and poor social support. Then ask about other internal
barriers, such as thoughts, emotions, our past experiences, our bodily states, our head
chatter. Allow group discussion of how these internal events get in the way of achieving
goals and moving toward our values.

43
Choosing Value Exercise
Identify a value on the board, like meaningful relationships with family. During
recovery, many people want to reconnect with family but have fears in doing so. Have
3x5 cards and pens ready.

Write the value Family on the dry erase board. Ask group participants to identify a
thought/emotion that may get in the way of making an attempt to reach out to family.
Have patients write down this thought or emotion on a 3x5 card. Some examples of
common thoughts related to family include:
Im afraid theyll reject me.
Im afraid they will judge me and say Im no good.
Theyll be angry with me.

Ask for five or six volunteers who are willing to share their thoughts that they wrote
down. Ask each person to stand up in the center of the room with their card.

Ask them to line up and one by one, walk by the group leader as they read the barrier out
loud. The group leader will be facing the dry erase board with the value written on it. As
each patient reads their statement, the group leader will agree with it & expound on it.
For example, saying Yes, yes, youre right, they should reject me, Ive let them down
for so long and have not been dependable. With each statement, the group leader turns a
little more away from facing the front (where the value is written on the board) toward
the back as he becomes more and more engrossed with these thoughts & emotions. He is
allowing himself to become distracted and pulled away from the value. Allow for
discussion about what patients observed about this process.

Ask patients to line up again and repeat the exercise. This time, the group leader will
face the front looking at the value. This time, as they read each statement, he will argue
with it. For example, saying No they wont reject me, Im doing well now; at least Im
in recovery. Again, as he argues, the group leader gets distracted by having to defend
against the thoughts and eventually turns away from the value. Allow for discussion
about what patients observed about this process.

Ask patients to line up again and repeat the exercise one last time. This time, the group
leader will face the value on the board & let each person walk by without responding
just watch them go by. .

Finally, the group leader will face the value on the board again. Ask each patient to get
behind the group leader and place their hands on the leaders shoulders. Ask them to
continuously read their statements in unison while the group leader slowly moves toward
the value on the board.
Note: More than likely, as everyone moves toward the board, their voices get louder &
louder.
Briefly summarize the main points observed over the four parts of the exercise.
So what people noticed is in the second part was that I stood up to my thoughts and this
is positive, not like in the first part, when I gave in to what my head was saying. Yes, that
44
may be true, but isnt it like our minds to argue and give in to our thoughts? When we
respond to our thoughts & emotions, we get caught up in them & lose contact with our
value - we get distracted. In both the first and second part, I got caught up and turned
away from the value. The third time, I did not fight with my thoughts and emotions; I let
them be. Then, I chose to go toward the value even though I have these thoughts &
emotions; I just took them with me. The head chatter may have gotten louder as I got
closer to the value, but isnt that just how our minds work a lot of the time?

Process Versus Outcome
Write the following sentence on the dry erase board.

Outcome is the process through which process becomes the outcome.

The Skiing Metaphor
Suppose you and I went skiing together and, feeling rather daring, we decided to do
extreme skiing. You know, you are flown by helicopter to the summit of a tall peak and
you ski your way straight downhill over crevasses, and glaciers. The challenge is to
somehow confront all these unpredictable obstacles and show up alive at the lodge. Now
the big day has arrived and as were getting on board the helicopter, you notice I have not
brought my skis, poles, parka and so forth. You ask me why I dont have my stuff with
me. My response is, Isnt the objective to get from the summit down to the lodge? I
thought thats what we were coming here for. The easiest way I know to do that is to
have them fly us up to the top and then fly us back down to the lodge. I point out that
flying up and down achieves exactly what flying up and skiing down achieves: Both have
me starting at the top and ending up at the lodge alive. And besides, one has me getting
cold, wet tired, thirsty, hungry and so on. The other has none of those discomforts and so
obviously is the best way to go. There is only one problem: we came here to ski, not ride
in helicopters. Skiing is not just the goal of getting to the lodge because any number of
activities can accomplish that for us. Skiing is how we are going to get there. Getting to
the lodge is important because it allows us to do the process of skiing in a direction. If I
tried to ski uphill instead of down it wouldnt work, so valuing down over up is
necessary. Outcome is the process through which the process can be the outcome.
Valuing getting down as a goal is the process through which we can reach our real goal:
to ski.

Facilitate group discussion about the problems of being too outcome focusedno
vitality, oppressive; always operating from a state of deprivation. Goals create motivation
& action, but solely focusing on them prevents us from experiencing NOW.

Homework Assignment
Hand out homework assignment and answer any questions about completing it.

45
Week Four: Values

Monday Homework Assignment

When the process of living becomes the outcome of interest, we are no longer living in a
world of deprivation.

How am I practicing living fully today?

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

What are some goals that are consistent with my values that can help me move forward
this week?
1. __________________________________________________________________
2. __________________________________________________________________
3. __________________________________________________________________

46
Week Four: Values


Values Reflection

FROM: You can't stop the waves but you can learn to surf
Jon Kabat-Zinn
Wherever you go there you are, pp 30-31.

People who come [here] quickly learn that stress is an inevitable part of life. While it is
true that we can learn, by making intelligent choices, not to make things worse for
ourselves in certain ways. There are so many things over which we have little or no
control. Stress is part of life, part of being human, intrinsic to the human condition itself.
But is does not mean that we have to be victims in the face of large forces in our lives.
We can learn to work with them, understand them, find meaning in them, make critical
choices, and use their energies to grow in strength, wisdom, and compassion.

One way to envision how [this] works is to think of your mind as the surface of a lake or
of the ocean. There are always waves on the water. Sometimes they are big, sometimes
they are small, and sometimes they are almost imperceptible. The water's waves are
churned up by winds, which come and go and vary in direction and intensity, just as do
the winds of stress and change in our lives, which stir up waves in our minds.
47
Week Four: Values


Group leaders need a copy of the original ACT book and pens for the group.

Review of Values
Review Monday curriculum and how values are related to ACT model. Discussion of
why values are an important part of treatment.
Write definitions of value and goals on the dry erase board.
Values are chosen life directions.
Goals are actions that you can measure, can achieve. They help us move toward
our values.

Discussion Points
How are they different? How are they similar?
What are some examples of values and goals?
What happens when values are out of line with our behavior?
What is the relationship of having goals and barriers? [By the very nature of
setting goals, one will encounter barriers. Without goals, there are not barriers.]

Compass Metaphor
Values can be thought of as a setting a compass toward a meaningful life for each
individual. Take the example of the wish to move west. If I were to leave Baltimore and
head west, Id arrive at Frederick, right? So would that be the end of heading west or
not? So the idea you get from this is that going to Frederick might be a goal of mine,
since it is west of here. But it wouldnt be the end point; it would be just a point along
my path of heading west.

The Path Up The Mountain Metaphor
Group Leader Note: This metaphor can be employed to help the client understand the
hazards of constantly monitoring immediate life outcomes rather than connecting with
valuing as a process.
Suppose you are taking a hike in the mountains. You know how they construct mountain
trails, especially if the slopes are steep. They wind back and forth; often they have
switchbacks where you literally walk back and forth and sometimes they will even
drop back down below a level youve already reached. If I asked you at any given point
on the trail to evaluate how well you are accomplishing your goal of reaching the
mountain top, I would hear a different story every time. If you were in switchback mode,
you would probably tell me that things werent going well, that you were never going to
reach the top. If you were in a stretch of open territory where you could see the mountain
top and the path leading up toward it, you would probably tell me things were going very
well. Now, imagine that we are across the valley looking at people hiking on this trail. If
we were asked how they were doing, we would have a positive progress report every
time. We would be able to see that the overall direction of the trail, not what it looks like
48
at a given moment, is the key to progress. We would see that following this crazy, windy
trail is exactly what leads to the top

Allow group discussion to reflect on this metaphor. Ask patients how the path up the
mountain may be similar to their own journey of recovery and treatment. Ask if there
have been times when it seemed like they may have been headed the wrong way, or
seemed as if they were headed downhill when they were trying to move toward the top of
the mountain. Elicit personal examples when patients are willing to do so. Ask patients
for their thoughts on why their journey might look different to a person across the valley
watching their progress? Finally, get ideas on how their perspectives may change as they
move along the path.

Identification of Personal Values and Goal Setting
Refer to Wednesday Journal Assignment (See page XX). Read the list of values to
patients out loud, stating these are some common life areas that people typically think are
important.
Id like to read you a list of nine areas that people often feel at important: friendship,
intimate relationships, family relationships, work, education, recreation, giving back
to others or citizenship, spirituality, and physical health and well-being. We have
been discussing how these are important to you this week. It may seem like all of these
are important, or you may have one or two areas that seem most relevant to you. Ill
invite you to focus your attention in a few of these areas.

Im going to read the list to you again, and then I want to ask you a question.
Friendship, intimate relationships, family relationships, work, education, recreation,
giving back to others or citizenship, spirituality, and physical health and well-being.
If you were to imagine three things that youd like for people to say about you after you
die, what would those three things be?

Hand out assignment to group members: Valued Areas of Life (See page XX). Ask
patients to pair up with the person sitting next to them and work in pairs. Instruct patients
that during this group, they will be asked to work on the first page with their partner.
They will be asked to work on the back page as the journal group assignment for
Thursday.

Ask patient to look at the list of Valued Areas of Life at the top of the page. Ask group
participants to choose one of the listed values to work on with their partner in group for a
few minutes. Make a general inquiry about participant's choices of which area they want
to focus on and ask about what they would imagine doing. Redirect choices that contain
fears, limitations, or reasons not to try.

Group leaders may choose to use a personal example to illustrate how to complete the
exercise on the dry erase board.
I decided to choose education/training for my area. So I will write that in the space by
1a. does everyone see where to write it?

49
Now look at 1b. If I were to imagine what I'd like to be doing to increase my knowledge
or skills, maybe I'd want to go to trade school or finish up a college degree. In 1b, I
would write what I'd LIKE to do in education. Ask patients for input for possible goals
in the area of education that the group leader might use.

Finally, look at area 1c. Please write down things that might get in the way of you
achieving your goals. Sometimes, this would come from outside of you, like the need to
focus on caring for family members or staying in treatment right now, rather than focus
on attending class.

Can you think of external reasons that I might not be able to attend to my educational
goals fully right now? What are some reasons on the INSIDE that I might not achieve
what I imagine? I might be afraid to take a class because I'd fail, or I'd feel bad that I was
a lot older than other people finishing a diploma.

Remember what we said about goals? It's absolutely certain that when we have goals,
we'll have barriers-some of them are outside of us, and some of them are from inside.
Your job is to realize that barriers are a completely normal part of taking action, not
something bad that's getting in the way. Having barriers means you're working toward
something that is of importance.

Ask group members to work with their partner for about ten minutes to complete the
front page of the exercise together, one for each of person. Encourage active problem
solving between each pair and specific goal setting. Remind patients of the aspects of a
good goal (SMART goals: Specific, Measurable, Attainable, Realistic and Time-limited).

Review instructions with patients as they get started. Write down your area here in the
A part, then about what you would LIKE have happen here in part B. Remember, this is
where you use your imagination. You'll probably have a lot of mental chatter about what
will "get in the way of doing your goal". Your job is write what you dream of, what you
hope for, and not worry about all the pitfalls. Now in area C, write down the pitfalls that
you thought of.

Allow patients approximately fifteen minutes to work together and then return to group
format. Facilitate discussion on their experience with identifying specific goals. Ask for
examples from patients about the areas they chose. Discuss what came up for people as
they attempted to set goals, such as thoughts about barriers. Ask about their experience
in identifying goals with a partner and if their partner helped them to stay on track when
barriers came up.Provide general feedback and encouragement. Recognize when inner
commentary gets in the way of setting a goalthat's something that can be
acknowledged, but it need not stop the process of making a commitment to a goal.
Suggest use of problem-solving skills, getting a second opinion, or acceptance for
external barriers.

Instruct patients to continue working on the back page for their journal group assignment.
50
Week Four: Values


Please choose three areas (listed below). Then write about what you would like to be
doing in that area. Finally, write some barriers to achieving these goals.

Valued Areas of Life

Intimate relationships Friendships
Family relationships Work/employment
Education/training Recreation
Giving back/Citizenship Spirituality
Physical health/Well-being

Example:
1a. Education
1b. Want to improve my education by pursuing my GED.
1c. Need to focus on treatment and work right now.

1a. Area of Life: _____________________________

1b. What would you like to be doing in this area (list what you imagine, as if you could
magically have whatever you want)?

1c. What are some reasons that you cannot move toward this valued direction? Please
consider reasons both outside (people, places, things) and inside yourself (beliefs,
thoughts, memories, feelings) that keep you from moving in this valued direction.

2a. Area of Life: _____________________________


51


3a. Area of Life: _____________________________



52
Week Four: Values


Gardening Metaphor
Imagine that you selected a spot to plant a garden. You worked the soil, planted the
seeds, and waited for them to sprout. Meanwhile, you started noticing a spot just across
the road, which also looked like a good spotmaybe even a better spot. So you pulled
up your vegetables and went across the street and planted another garden there. Then you
noticed another spot that looked even better. Values are like a spot where you plant a
garden. You can grow some things very quickly, but other things require time and
dedication. The question is, Do you want to live on lettuce, or do you want to live on
something more substantialpotatoes, beets, and the like? You cant find out how
things work in gardens when you have to pull up stakes again and again. Of course, if
you stay in the same spot, youll start to notice its imperfections. Maybe the ground isnt
quite as level as it looked when you started, or perhaps the water has to be carried for
quite a distance. Some things you plant may seem to take forever to come up. It is at
times like this that your mind will tell you, you should have planted elsewhere, This
will probably never work, It was stupid of you to think you could grow anything here,
and so on. The choice to garden here allows you to water and weed and hoe, even when
these thoughts and feelings show up.

Reflection Question: What is your garden and what commitment can you make to it this
week?

53
Week Five: Committed Action (J ust Do I t)


Group leader will write Just do it on the dry erase board to begin Quiet Reflection.

Hitting a baseball
There are lots of books and videotapes instructing people how to hit baseballs. A person
can read all the books, watch all the instructional videos, go to games, interview players,
even swing the bat in their own backyard. But can a person actually hit a baseball by
doing any of these things?

No.

What is the only way to hit a baseball?

Step up to the plate during a game and take a swing.

Discussion Points:
We can talk, think, and plan as much as we want. None of that has any bearing
whatsoever on our everyday life until we change what we do.
Substance abuse area is overflowing with sayings, clichs, aphorisms (give
examples), but none of them means anythingthey are just words.
Commitment is not to words but to actions. The commitment is to the effort, the
act itself, not to any consequences. Are you trying to move closer to aligning with
your values?
This is not about feeling good; you may feel worse while you are aligning with
your values. It is more about feeling well.

Reflection Questions:
What can I change TODAY?
What can I change THIS WEEKEND?
What can I change NEXT WEEK?
What can I change after that?
54
Week Five: Committed Action

Monday Curriculum

Group leaders will need a dry erase board, markers, handouts and pens for the group.

Review of ACT Rationale
Briefly review Control as the Problem, Willingness, Defusion and Values concepts from
previous weeks for new members. Ask participants for thoughts on Monday Quiet
Reflection, relating this to themes discussed in previous weeks.

Definition of Commitment
Review the definitions of commitment by asking the group to list the characteristics of
each & write them on the board.

Commit: to do, perform, or perpetrate; to bind or obligate
Commitment: the state of being bound emotionally or intellectually to a course of action.

Differentiate between the word, what it means to patients and the implications of
commitment. What place do words occupy in the process of making a commitment?
Slogans and saying (e.g., One day at a time, Stick and stay) are often used to motivate
people in recovery toward their commitments. However, words actually dont factor into
commitment at all. Facilitate discussion about what makes a commitment if words by
themselves can not actually make a commitment. Guide group members toward the idea
that commitment means actions.

Outcomes
Facilitate group discussion on the distinction between making commitments and the
outcomes of commitments. What is the relationship between the two? What does an
outcome or an expected outcome have to do with the original intent to commit to a course
of action? It most often has to do with our story of how we wish things will turn out.
Relate this relationship back to the idea of willingness and power/control. Do we have
any control over the actual outcome of our behaviors when we set out on a course of
action? What matters is the ACT, not how it turns out. What matters is picking a course
of action that is consistent with our values and making choices on that path each day.

Barriers to Commitment
Group leader will write: It would work in my life to do this, so therefore, Im doing it.
Facilitate discussion on this statement. Although it seems easy and simple enough, many
things get in our way when we think about making a commitment to a course of action.
Relate this concept to the baseball metaphor from Monday Quiet Reflection. Ask group
members to discuss why a person would do everything but get to the plate in a game and
swing the bat? Write their answers on the dry erase board.

Many of the answers may revolve around a common theme of fear, or participants may
give this answer directly. There are two types of fear: fear of failure and fear of success.
55
Individuals with substance abuse will often relate to fear of success, particularly those
with very long histories of use. People with histories of trauma typically have a difficult
time experiencing vulnerability. Fear of success can open a person up to a heightened
sense of vulnerability, which can also interfere with committing to something outside
their habitual way of living. Perceived interpersonal rejection and fear of letting others
down (again) can be an internal barrier for many patients in the group. Validate these
experiences and express that all committed action inevitably involves discomfort and
unwanted internal experiences.

Setting Goals
Ask group members if they are willing to pair up with the person next to them to
complete a worksheet on goal-setting. Hand out Setting Goals Worksheet (See page
XX).

Instruct patients to write their goals on the sheet without using any slogans, mottos,
clichs, aphorisms, sayings, words of wisdom, jargon, catch-phrases, steps, or lingo. As
patients work in pairs, ask them to help each other set concrete examples of what each
person would like to change, and how things would be different if this was changed. For
each goal, ask patients to think of one thing that can get in the way of sticking to his or
her commitment. And then, identify specific things each person will do when these
things happen.

Homework Assignment
Hand out Committed Action Worksheet (See page XX) for homework. Answer any
questions about completing it.

56
Setting Goals Worksheet

Instructions: Write down your goals on the sheet. Use specific examples of what you
would like to change, and how things would be different if it were. For each goal, think
of one thing that can get in the way of sticking to your commitment. Even more
important, think of specific things you will do when these things happen.

Goal #1 (write this in plain English, without catch phrases, slogans etc.):

Barrier (what is one thing that will get in the way of this goal)?

Plan (how will I deal with the barrier effectively)?







57

Homework Assignment

Committed Action Worksheet

The purpose of this worksheet is to identify some of your immediate goals in the service
of your longer-term values. For each goal, write down the likely obstacles to that goal
(the things that will get in the way or make you hesitate to make a change). Then write
down what you can do about that obstacle. Note whether it is something you can change
or whether it is something you will have to live with.

Goal

Obstacles
What can I do about the
obstacles?
(Can I change them? Do I have
to put up with them?)

58



The Swamp Metaphor,

This is like you are beginning a journey to a beautiful mountain you can clearly see in
the distance. No sooner do you start the hike than you walk right into a swamp which
extends out as far as you can see in all directions. You say to yourself, Gee, I didnt
realize that I was going to have go through a swamp. Its all smelly and the mud is all
mushy in my shoes. Its hard to lift my feet out of the muck and put them forward. Im
wet and tired. Why didnt anybody tell me about this swamp. When that happens you
have a choice: abandon the journey or enter the swamp. Therapy is like that. Life is like
that. We go into the swamp not because we want to get muddy but because it stands
between us and where we are going

Another way to legitimize the appearance of new obstacles is reframe it as a sign of
positive growth. There is an old saying in strategic therapy that applies here: Life is one
damn thing after another. Our job is to make sure its not the same damn thing. The
necessity of growth and struggle together in life is a hard message to hear and it certainly
gets only flimsy support from the language community.

59


Review of ACT Protocol
Review of Monday curriculum and overall concepts of model introduced in protocol for
new patients. Ask patients for thoughts on Wednesday Quiet Reflection and relate
discussion points to making commitments to valued living.

Long-term and Short-term Consequences of Recovery
Facilitate discussion among group members about actions chosen based on short-term
and long-term discomfort. What does using substances help individuals gain in the short
term? Long term? What does using substances cost in the short term? Long term?
People generally choose not to act because we want to avoid short-term discomfort, yet
we are able to ignore very severe long-term consequences in order to avoid immediate
discomfort.

Early in recovery, it is often the case that patients can recall more of the negatives of
using substances. When asked, there are many reasons a patient can cite for wanting to
remain clean. The long term positives can also be easily listed, such as re-establishing
relationships and maintaining financial stability. However, as more clean time is
acquired, the negative consequences of using become less salient. Once these negatives
of using disappear in recovery, one is in danger or relapse.

Scale Metaphor
Ask group participants to connect with their reasons for making a change with their
substance use. Ask for specific negative consequences of substance use. Allow time for
a large list to develop; the group leader should write the responses on the dry erase board.
Next, ask patients to list the reasons they have used in the past. At first, patients may
resist connecting with positives of drug use, stating there are no good reasons to use.
Help patients to identify with the idea that something was beneficial about using. The
importance of recognizing what this was will help them recognize it in the future,
because the thought will pass through their heads again. There is no shame or judgment
in knowing that it is simply a thought that they can choose not to act on.

Write all negative consequences on one side of the dry erase board and positives on the
opposite side, representing a scale. List enough to balance both sides equally. Notice out
loud to patients how both sides balance out early in recovery.

Then discuss the process of recovery, as one begins to build more positive things into his
or her life, the negative consequences become less prominent. For example, with more
clean time, it becomes easier to find stable employment. With regular paychecks,
housing and transportation become less of an issue. There are typically less legal
consequences when one is engaging in these types of law-abiding activities. As the
group leader lists each one, he erases this concept from the negatives side of the scale.
Notice with patients how empty the negative side can become after several months of
60
clean time. Emphasize the fact that the focus needs to shift on the long-term benefits of
recovery in order to continue with sobriety, or maintaining weight on both sides of the
scale. If patients continue to focus on the absence of negative consequences, they may be
left with little to rely on to maintain motivation after some clean time.

Commitment Balance
Hand out journal group assignment, Commitment Balance (See Page XX). Relate this to
the scale just created on the dry erase board. Discuss with patients that this worksheet is
their own personalized scale. Identify the importance of recognizing their own reasons
for wanting to remain clean. Identify the difficult times and struggles that may increase
their urges to use that this exercise will become crucial in those moments. Facilitate
discussion about how this assignment may best be utilized in those moments (e.g.,
carrying a copy in their wallet, sharing with family and friends, etc).

Assign decisional balance to be worked on before next journal group. Answer any
questions about assignment or how to complete it.

61

COMMITMENT BALANCE WORKSHEET
The purpose of this worksheet is to help you consider all the
consequences of a decision, in order to help you decide whether to
commit to changing your behavior. You can use the worksheet to
help you examine your decision in any important area. Remember to
pay close attention to how consistent each option is with your longer-
term values (or the way you would like your life to be).

First, think of an area of VALUE in your life- what is something that
is important to you?

Next, identify something about that area of your life that is not
working for you. Then, choose another way of doing things that is
more consistent with what you really value.

Short-term can be in the next hour, the next day, or the next week.
Long-term can be a week from now, a month from now, or five
years from now.

Remember, a commitment consists of the following: It would work for
me in my life to do this, and therefore Im doing it.

A commitment should not be made unless youre 100% certain you
intend to keep it. This doesnt mean that you wont sometimes slip
and fail; it means that if this does happen, you will get back up, point
yourself back in the direction you want to go, and keep going. It also
means that you are committed to changing the obstacles that you can
change, and you are willing to sit with the emotions, feelings, and
thoughts that you cant change.

Remember: Just do it

Intimate relationships, Recreation, Friendships, Family
relationships, Work/employment Education/training, Giving
back/Citizenship, Spirituality, Physical health/Well-being
62
Commitment Balance

Short-term

Long-term

Positive

Negative

Positive

Negative

If I
continue
to

(What will
happen
If I continue
to do
things
exactly as
I am doing
now)

If I change
and start
to...

(How will
things be
different if I
change my
behavior?)

63



Just Do It.
Nike Slogan

Reflection Meditation: There is never a good time to make a change. Consequently,
there is never a bad time. Theres only the present.

64

Patient Handouts
65
Acceptance and Commitment Training (ACT)
Program Philosophy Statement

Pain is inevitable, suffering is optional.
-- Sylvia Boorstein

We know that individuals with substance abuse problems or PTSD have a tendency to
avoid painful memories and engage in behaviors to distance themselves from their pain.
Although these strategies may have worked in the short term, we believe that efforts at
avoidance are ineffective, and even harmful, in the long run. This program is about
becoming willing to make more space in our lives so that we are able to hold all the
painful thoughts, memories and experiences life has dealt us without dodging them
through the use of substances, AND at the same time move in the direction we value.

We strive to find meaning in our lives by letting ourselves and others know what is really
important to us what we value most. This treatment isnt about what is good or
bad, or what is right or wrong; the most important question at stake here is, How
well has this been working for me? One of our most important tasks is to honestly take
stock of what actions, relationships and life activities will help us live a vital and valued
life. For many of us, past or present behaviors such as substance use, avoidance due to
PTSD, or other difficulties may be causing us to behave in a way that is out of line with
our values.

In all of our activities in the ACT Program, whether they be group therapy, individual
counseling, or informal interactions with each other, we will work on:
Willingness to experience the full range of feelings, memories, and thoughts that
we have on a daily basis, without attempting to get rid of or avoid those that we
find difficult or uncomfortable
Being able to make an honest evaluation of our actions and beliefs in order to
determine how well they are working
Coping skills as alternatives for avoiding or using substances
Developing and participating in a social network
Commitment to moving forward in our lives, in a direction determined by our
individual values

This treatment is about living in a way that is rich, full, and vital, and that lines up with
our values. In this program, we choose life.

66
Workability Quotes

"Life is "trying things to see if they work."
Ray Bradbury

I cannot say whether things will get better if we change; what I can say is they must
change if they are to get better.
Georg Christoph Lichtenberg

If the only tool you have is a hammer, you tend to see every problem as a nail.
Abraham Maslow

The definition of insanity: Doing the same things youve always done and expecting
different results.
How Do You Dig?

As we discussed today, we all sometimes make the mistake of trying to dig our way out
of a hole. Of course, this only gets us deeper and deeper in the hole. For Wednesday, Id
like you to work on identifying some of the things that you do that get you more and
more STUCK!

In preparation for next weeks group, please identify 3 things that you do that are
digging in your life things that you do that are meant to solve your problems but just
seem to work in the short term, dont work at all, or maybe even make things worse.
Anything that keeps you stuck would be considered digging.

Digging #1:

Digging #2:

Digging #3:

68

69

1. Like in the quicksand metaphor, could you be willing to stop struggling with your
own thoughts, feelings, memories, bodily sensations, etc. and instead just stay
still, and be in contact with them? What reactions do you have to that idea?

2. What would you have to do in order to stop struggling? Imagine yourself actually
doing this. What would it look like? What would you be doing instead?

Hows That Working For You?
70
Imagine that the course of your life depends on you steering a car down a road in the
direction of whats important to you. And so at the beginning of this process, you get into
your car and take off down the highway. Unfortunately, whoever taught you how to
drive told you that the way to steer the car is by holding onto and turning the rear-view
mirror.

Now, you might be able to go a long way once you start down the road without anything
much happening, depending on whether the road youre on is straight, or whether there is
much oncoming traffic, and so on. Eventually, however, the car is going to crash. So,
what you do is dust yourself off, start the car again, grab the rear-view mirror, and start
driving again. But you keep crashing!

The problem isnt with the car, or with the driver; the problem is that you cant steer a car
with the rear-view mirror! What were working on here is about teaching you to put your
hands on the steering wheel instead of the rear-view mirror. Our focus is less on where
you have been, and more on where you are going and how to get there.

Reflection Question: Have I been steering my life using the steering wheel, or the
rearview mirror? What would I need to do to plant my hands more firmly on the
steering wheel?
71
Willingness Quotes

If nothing changes, nothing changes.
Ernie Larson

If you do what you always did, youll get what you always got.
Moms Mabley

Reflection Question: How can you stop doing what doesnt work AND are you
willing to try something different?

Requires ACCEPTANCE and WILLINGNESS and COURAGE

COURAGE (literally, to have heart): the attitude of facing and dealing with
anything recognized as difficult or painful, instead of withdrawing from it

72
Control and Willingness

Identify a situation, person, or event that you have had difficulty accepting.

What thoughts do you have about this situation, person, or event?

What emotional reactions come up for you when you think about this situation, person, or
event?

Who would you be IF you were able to accept this situation, person, or event exactly as it
is? How would you be different? How would your life be different?

73

HEAVEN AND HELL

Theres another story that you may have read that has to do with what we call
heaven and hell, life and death, good and bad. Its a story about how those things dont
really exist except as a creation of our own minds. It goes like this: A big burly samurai
comes to the wise man and says, Tell me the nature of heaven and hell. And the roshi
looks him in the face and says: Why should I tell a scruffy, disgusting, miserable slob
like you? The samurai starts to get purple in the face, his hair starts to stand up, but the
roshi wont stop. He keeps saying, A miserable worm like you, do you think I should
tell you anything? Consumed by rage, the samurai draws his sword and hes just about
to cut off the head of the roshi. The roshi says, Thats hell. The samurai, who is in fact
a sensitive person, instantly gets it, that he just created his own hell; he was deep in hell.
It was black and hot, filled with hatred, self-protection, anger, and resentment, so much
so that he was going to kill this man. Tears fill his eyes and he starts to cry and he puts
his palms together and the roshi says, Thats heaven.

There isnt any hell or heaven except for how we relate to our world. Hell is just
resistance to life. When you want to say no to the situation youre in, its fine to say no,
but when you build up a big case to the point where youre so convinced that you would
draw your sword and cut off someones head, that kind of resistance to life is hell.

In the way we practice, we dont say, Hell is bad and heaven is good or Get rid
of hell and just seek heaven, but we encourage ourselves to develop an open heart and
an open mind to heaven, to hell, to everything. Why? Because only then can be realize
that no matter what comes along, were always standing at the center of the work in the
middle of sacred space, and everything that comes into that circle and exists with us there
has come to teach us what we need to know.

Lifes work is to wake up, to let the things that enter into the circle wake you up
rather than put you to sleep. The only way to do this is to open, be curious, and develop
some sense of sympathy for everything that comes along, to get to know its nature and let
it teach you what it will. Its going to stick around until you learn your lesson at any rate.
You can leave your marriage, you can quit your job, you can only go where people are
going to praise you, you can manipulate your world until youre blue in the face to try to
make it always smooth, but the same old demons will always come up until finally you
have learned your lesson, the lesson they came to teach you. Then those same demons
will appear as friendly, warmhearted companions on the path.

Pema Chodron
The Wisdom of No Escape and the Path of Loving-kindness
pp. 31-32

74

Pain is inevitable; suffering is optional.

This week we are discussing how we tend to make our problems worse and
increase our suffering by refusing to accept reality as it is RIGHT NOW, and by our
unwillingness to experience whatever thoughts, feelings, memories, and physical
sensations accompany that reality. We call this dirty discomfort. In the story of the
Samurai, the wise man taught him how he had created his own hell by his
unwillingness to accept the situation for what it was.

3. How do you create dirty discomfort for yourself? How do you take a stressful
situation and make it worse? In your journal entry, please write about something that
happened today in which your unwillingness to accept the reality of the situation ended
up making things WORSE for you!

4. Next, write about a situation that happened today in which your willingness to
accept the situation as it was, and your willingness to own your feelings, thoughts, and
reactions to the situation, brought you at least a little taste of peacefulness and calm

75

Willingness Reflection

A. CONTROL AND AVOIDANCE
OR
B. ACCEPTANCE AND WILLINGNESS

Identify the approach (A or B) that best fits each of the statements below:

____ When negative experiences occur, the goal is to get rid of them or get them
under control so that they hurt less.

____ The attempt to control or get rid of negative experiences creates problems; the
goal is to let them be there, and they will change as a natural part of living.

____ The way to understand negative experiences is to understand why I am having
them, and then use that knowledge to eliminate them.

____ The way to understand negative experiences is to notice that they are present
without necessarily analyzing them or judging them.

76
Defusion Reflection

"Do we control what we think?"

Facilitate debate of this topic for 10 minutes

Reflection Question: What would it mean if we do control our thoughts and what
would it mean if we don't actually control our thoughts?

RECOVERY POP-QUIZ
77

1. I think, therefore I am T F

2. If this program teaches me anything, T F
its that avoidance is always unhealthy

3. The more I try to stop a thought, the
stronger the thought becomes T F

4. In recovery, behaviors must change T F
but my thoughts and feelings are OK
the way they are.

78
Reacting to Uncomfortable Emotions

AVOIDANCE
Stuffing It------------------------------------------------------------------------Acting It Out

Responding to Uncomfortable Emotions:

EXPERIENCING IT
"Sitting with it"

List two emotions that you wish you could get rid of.
________________________________________________________________________
________________________________________________________________________

How have you tried to avoid/get rid of each of the two emotions you listed?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

How has trying to get rid of these emotions gotten in the way of living a valued life?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
79
Take Your Keys With You

For your journal group assignment this week, identify several different emotions,
thoughts, memories, or sensations you have been struggling with lately. These can be
about trauma, substance abuse, or both.

Examples include:

I dont think I can ever stop using.
I will never make up all my years of using to my family.
Tightness in chest, restlessness, or other sensations of anxiety and cravings
Memories of your trauma

Write your own examples here:

1. _______________________________________________________

2.________________________________________________________

3. _______________________________________________________

Now, take 3 small pieces of paper. Write your examples on the papers. Then, tape the
papers to 3 keys on your key ring. If you are willing, your homework is to carry your
keys, and your thoughts, memories, feelings, and sensations, with you for the next week.

Journal about several things during the next week about your experience carrying your
keys:

How much effort does it take to carry your keys with you?

What places can you go, or not go, depending on whether you have your keys
with you?

Does picking up your keys and carrying them with you prevent your from going
anywhere?

80
Cravings News Radio Metaphor

CRAVINGS NEWS RADIO (WSNR): This is Cravings News Radio, WSNR,
broadcasting inside your head, twenty hours a day, seven days a week. Wherever you
are, the signal will reach you. When you wake in the early hours, well be there to make
you aware of your craving to smoke, even before you get out of bed. Let us take over
and control your life. Cravings News Radio is compelling listening, and guess why? Its
the news station youve lived with for years, and now comes to you automatically, 24/7.
Pay attention! Cravings News Radio knows whats best for you and we want you to buy
our products. We advertise the products you fear most and want to avoid. So dont
forget that, and remember, if you should forget us and ACT without seeking permission,
then well broadcast all the louder. Remember, having cravings can be really awful, so
you should stay tuned to this station to know how to avoid them.

JUST SO RADIO (WJSR): Wake up! Cravings News Radio is just a station you can
tune in, or you can tune out! One thing is guaranteed though, whatever the time of day,
youll hear the same old stuff on WSNR. If thats been really helpful to you, then go
ahead, tune in and stay tuned. That would make sense. If not, then tune in more often to
Just So radio. We bring you the news of actual experience, in the moment, all live, all the
time. Actuality is out business! We give it to you straight as it is, not as your mind
says it is. In contact with the world outside and inside the skin, you can experience what
it is to be human, and its entirely free! We can guarantee that experiencing whats inside
the skin exactly as it is will never damage you, but it just might bring you joy. Just
So Radio brings you information about how things are, not how you fear they might be.
Just So Radio invites you to step forward and touch the world, just as it is, and to touch
your life, just as it is. We get louder the more you listen to us. So stay tuned. Give us a
fair trial, and if not convinced by your own experience (please dont take our word for it)
then WSNR 9 Cravings News Radio is still there on the dial.

81
Values Reflections
A little over ten years ago, as I was beginning my journey to integrating sacred
pampering and self-care into my life, I thought that having more joy and deep satisfaction
in my life was a matter of getting my priorities straight. A priority is something we
regard as more important than something else. But I discovered that having more joy in
my life didnt come about as a result of getting my priorities straight, but from having my
actions and behaviors consistent with what I said I valued. What you value is what you
consider significant and important.

An assessment of where, how, when, and with whom we invest our time and energy is an
accurate and telling barometer for where our priorities lie. We think that we act in
accordance with what we value. This is usually not the case. Most of us are usually
doing the oppositeour actions and behaviors are supporting something very different
from what we say is important to us. Unfortunately, this is the norm.

When your behavior is at odds with what you value, you experience anxiety,
dissatisfaction, spiritual constipation, and internal conflict. These are by-products of
the head-on collision of our behaviors and our values. What you value is a function of
your beliefs. Someones values, and thus his or her beliefs, show through a persons
actions, behaviors, and choices. In other words, demonstration is the vehicle through
which our values are revealed. When you say your values are one thing yet your actions
and behaviors demonstrate another, you undermine your power, integrity, and spiritual
energy.
Debrena Jackson Gandy, from All The Joy You Can Stand

You dont get to choose how youre going to die. Or when. You can only decide how
youre going to live. Now.
Joan Baez

He who is not courageous enough to take risks will accomplish nothing in life.
Muhammed Ali

82
When the process of living becomes the outcome of interest, we are no longer living in a
world of deprivation.

How am I practicing living fully today?

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

What are some goals that are consistent with my values that can help me move forward
this week?
4. __________________________________________________________________
5. __________________________________________________________________
6. __________________________________________________________________

83
Values Reflection
FROM: You can't stop the waves but you can learn to surf
Jon Kabat-Zinn
Wherever you go there you are, pp 30-31.

People who come [here] quickly learn that stress is an inevitable part of life. While it is
true that we can learn, by making intelligent choices, not to make things worse for
ourselves in certain ways. There are so many things over which we have little or no
control. Stress is part of life, part of being human, intrinsic to the human condition itself.
But is does not mean that we have to be victims in the face of large forces in our lives.
We can learn to work with them, understand them, find meaning in them, make critical
choices, and use their energies to grow in strength, wisdom, and compassion.

One way to envision how [this] works is to think of your mind as the surface of a lake or
of the ocean. There are always waves on the water. Sometimes they are big, sometimes
they are small, and sometimes they are almost imperceptible. The water's waves are
churned up by winds, which come and go and vary in direction and intensity, just as do
the winds of stress and change in our lives, which stir up waves in our minds.

84

Please choose three areas (listed below). Then write about what you would like to be
doing in that area. Finally, write some barriers to achieving these goals.

Valued Areas of Life

Intimate relationships Friendships
Family relationships Work/employment
Education/training Recreation
Giving back/Citizenship Spirituality
Physical health/Well-being

Example:
1a. Education
1b. Want to improve my education by pursuing my GED.
1c. Need to focus on treatment and work right now.

1a. Area of Life: _____________________________



2a. Area of Life: _____________________________


85

3a. Area of Life: _____________________________



86
Values Reflection
Imagine that you selected a spot to plant a garden. You worked the soil, planted the
seeds, and waited for them to sprout. Meanwhile, you started noticing a spot just across
the road, which also looked like a good spotmaybe even a better spot. So you pulled
up your vegetables and went across the street and planted another garden there. Then you
noticed another spot that looked even better. Values are like a spot where you plant a
garden. You can grow some things very quickly, but other things require time and
dedication. The question is, Do you want to live on lettuce, or do you want to live on
something more substantialpotatoes, beets, and the like? You cant find out how
things work in gardens when you have to pull up stakes again and again. Of course, if
you stay in the same spot, youll start to notice its imperfections. Maybe the ground isnt
quite as level as it looked when you started, or perhaps the water has to be carried for
quite a distance. Some things you plant may seem to take forever to come up. It is at
times like this that your mind will tell you, you should have planted elsewhere, This
will probably never work, It was stupid of you to think you could grow anything here,
and so on. The choice to garden here allows you to water and weed and hoe, even when
these thoughts and feelings show up.

Reflection Question: What is your garden and what commitment can you make to it this
week?
87
Setting Goals Worksheet

Instructions: Write down your goals on the sheet. Use specific examples of what you
would like to change, and how things would be different if it were. For each goal, think
of one thing that can get in the way of sticking to your commitment. Even more
important, think of specific things you will do when these things happen.










88

Committed Action Worksheet

The purpose of this worksheet is to identify some of your immediate goals in the service
of your longer-term values. For each goal, write down the likely obstacles to that goal
(the things that will get in the way or make you hesitate to make a change). Then write
down what you can do about that obstacle. Note whether it is something you can change
or whether it is something you will have to live with.

Goal

Obstacles
What can I do about the
obstacles?
(Can I change them? Do I have
to put up with them?)

89
COMMITMENT BALANCE WORKSHEET
The purpose of this worksheet is to help you consider all the
consequences of a decision, in order to help you decide whether to
commit to changing your behavior. You can use the worksheet to
help you examine your decision in any important area. Remember to
pay close attention to how consistent each option is with your longer-
term values (or the way you would like your life to be).

First, think of an area of VALUE in your life- what is something that
is important to you?

Next, identify something about that area of your life that is not
working for you. Then, choose another way of doing things that is
more consistent with what you really value.

Short-term can be in the next hour, the next day, or the next week.
Long-term can be a week from now, a month from now, or five
years from now.

Remember, a commitment consists of the following: It would work for
me in my life to do this, and therefore Im doing it.

A commitment should not be made unless youre 100% certain you
intend to keep it. This doesnt mean that you wont sometimes slip
and fail; it means that if this does happen, you will get back up, point
yourself back in the direction you want to go, and keep going. It also
means that you are committed to changing the obstacles that you can
change, and you are willing to sit with the emotions, feelings, and
thoughts that you cant change.

Remember: Just do it

Intimate relationships, Recreation, Friendships, Family
relationships, Work/employment Education/training, Giving
back/Citizenship, Spirituality, Physical health/Well-being

90

Short-term

Long-term

Positive

Negative

Positive

Negative

If I
continue
to

(What will
happen
If I continue
to do
things
exactly as
I am doing
now)

If I change
and start
to...

(How will
things be
different if I
change my
behavior?)

91

Committed Action Reflection

Just Do It.
Nike Slogan

Reflection Meditation: There is never a good time to make a change. Consequently,
there is never a bad time. Theres only the present.

ACTProtocol VAMHCS

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