https://www.psychotherapy.net/article/Acceptance-and-Commitment-Therapy-ACT
1. Cognitive Defusion: learning to perceive thoughts, images, memories and other cognitions as what they are—nothing more than bits of language, words and pictures—as opposed to what they can appear to be—threatening events, rules that must be obeyed, objective truths and facts.
In session two, Michael said he experienced frequent distress from thoughts such as “I'm boring,” “I have nothing to say,” “No one likes me,” and “I'm a loser.” As the session continued, I had Michael interact with these thoughts in a number or different ways, until they began to lose their impact. For example, I had him bring to mind the thought “I'm a loser,” then close his eyes and notice where it seemed to be located in space. He sensed it was in front of him. I asked him to observe the thought as if he was a curious scientist, and to notice the form of it: whether it was more like something he could see, or something he could hear. He said it was like words that he could see, and he noticed that as he “looked” at it, it became less distressing.
I asked him to imagine the thought as words on a Karaoke screen; then change the font; then change the color; then imagine a bouncing ball jumping from word to word.
I asked him to imagine the thought as words on a Karaoke screen; then change the font; then change the color; then imagine a bouncing ball jumping from word to word. By this stage, Michael was chuckling at the very same thought that only a few minutes earlier had brought him to tears. “Homework” included practicing several different defusion techniques with distressing thoughts—not to get rid of them, but simply to learn how to step back and see them for what they are—just “bits of language” passing through.
2. Acceptance: making room for unpleasant feelings, sensations, urges, and other private experiences; allowing them to come and go without struggling with them, running from them, or giving them undue attention.
In session three, I asked Michael to make himself anxious by imagining himself at a forthcoming office party. When I asked him to scan his body and notice where he felt the anxiety most intensely he reported a “huge knot” in his stomach. I asked him to observe this sensation as if he was a curious scientist who had never seen anything like it before; to notice the edges of it, the shape of it, the vibration, weight, temperature, pulsation, and the myriad of other sensations within the sensation. I had him breathe into the sensation, and “make room for it”; to allow it to be there even though he did not like it or want it. Michael soon reported a sense of calmness; a sense of being at ease with his anxiety even though he didn't like it. “Homework” included practicing this technique with his recurrent feelings of anxiety—not to get rid of them, but simply to learn how to let them come and go without a struggle.
3. Contact with the present moment: bringing full awareness to your here-and-now experience, with openness, interest, and receptiveness; focusing on, and engaging fully in whatever you are doing.
In session four, I took Michael through a simple mindfulness exercise, focused on the experience of eating. I gave him a sultana, and asked him to eat it “in slow motion,” with a total focus on the taste and texture of the fruit, and the sounds, sensations and movements inside his mouth. I told him, “While you're doing this, all sorts of distracting thoughts and feelings may arise. The aim is simply to let your thoughts come and go, and allow your feelings to be there, and keep your attention focused on eating the sultana.”
Afterwards, Michael said he was amazed that there was so much flavor in one single sultana. I was then able to use this experience to draw an analogy with social situations, where Michael would he so caught up in his thoughts and feelings that he wasn't able to engage fully in conversation, and missed out on the “richness.” “Homework” included practicing full engagement with all the five senses in a number of daily routines (having a shower, brushing his teeth, and washing the dishes) as well as continuing to practice his defusion and acceptance techniques. He agreed also to practice mindful engagement in conversations; i.e. keeping his attention on the other person, rather than on his own thoughts and feelings.
4. The Observing Self: accessing a transcendent sense of self; a continuity of consciousness that is unchanging, ever-present, and impervious to harm. From this perspective, it is possible to experience directly that you are not your thoughts, feelings, memories, urges, sensations, images, roles, or physical body. These phenomena change constantly and are peripheral aspects of you, but they are not the essence of who you are.
The Observing Self: accessing a transcendent sense of self; a continuity of consciousness that is unchanging, ever-present, and impervious to harm.
In session five, I took Michael through a mindfulness exercise designed to have him access this transcendent self. First, I asked him to close his eyes and observe his thoughts: the form they rook, their apparent location in space, the speed with which they were moving. Then I asked him: “Be aware of what you are noticing. There are your thoughts, and there you are noticing them. So there are two processes going on—a process of thinking, and a process of observing that thinking.” Again and again, I drew his attention to the distinction between the thoughts that arise, and the self who observes those thoughts. From the perspective of the Observing Self, no thought is dangerous, threatening, or controlling.
5. Values: clarifying what is most important, deep in your heart; what sort of person you want to be; what is significant and meaningful to you; and what you want to stand for in this life.
In session six, Michael identified important values around connecting with others, building meaningful friendships, developing intimacy, and being authentic and genuine. We discussed the concept of willingness. The willingness to feel anxiety doesn't mean you like or want it. Instead it means you allow it to be there in order to do something you value. I asked Michael, “If taking your life in the direction of these values means you need to make room for feelings of anxiety, are you willing to do that?” His reply was, “Yes.”
6. Committed Action: setting goals, guided by your values, and taking effective action to achieve them.
Continuing session six, we moved to setting goals in line with Michael's values. Initially, he set the goal of going for lunch with a work colleague every day, and sharing some personal information on each occasion. In subsequent sessions, he set increasingly challenging social goals, and continued to practice mindfulness skills to handle the anxious thoughts and feelings that inevitably arose. At the end of ten sessions, Michael reported that he was socializing a lot more, and more importantly, he was enjoying it. Thoughts of being “a loser” or “boring” or “unlikeable” still occurred, but usually he did not take them seriously or pay them any attention. Likewise, feelings of anxiety still occurred in many social situations, but no longer bothered him or distracted him. Overall, his anxiety levels had diminished considerably. This reduction in anxiety was not the goal of therapy, but was a pleasant by-product.
This illustrates how ACT can result in good symptom reduction without ever aiming for it. First, a lot of exposure took place, as Michael engaged in increasingly challenging social situations. It is well known that exposure frequently can lead to reduced anxiety. Second, the more accepting Michael became of his unwanted thoughts and feelings, the less anxiety he had about those thoughts and feelings. Indeed, practicing mindfulness of unwanted thoughts and feelings is a form of exposure in itself.
