Trauma-Focused ACT: A Practitioner’s Guide to Working with Mind, Body, and Emotion Using Acceptance and Commitment Therapy

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“Trauma-Focused ACT is going to go down as one of the great contributions to the field of trauma-informed care.” —Kirk Strosahl PhD, cofounder of ACT Trauma-Focused ACT (TFACT) provides a flexible, comprehensive model for treating the entire spectrum of trauma-related issues, including post-traumatic stress disorder (PTSD), addiction, depression, anxiety disorders, moral injury, chronic pain, shame, suicidality, insomnia, complicated grief, attachment issues, sexual problems, and more. Written by internationally acclaimed ACT trainer, Russ Harris, this textbook is for practitioners at all levels of experience, and offers exclusive access to free downloadable resources—including scripts, videos, MP3s, handouts, and worksheets. Discover cutting-edge strategies for healing the past, living in the present, and building a new future. With this compassion-based, exposure-centered approach, you’ll learn how to help your clients: Find safety and security in their bodiesOvercome hyperarousal and hypoarousalBreak free from dissociationShift from self-hatred to self-compassionRapidly ground themselves and reengage in lifeUnhook from difficult cognitions and emotionsDevelop an integrated sense of selfResolve traumatic memories through flexible exposureConnect with and live by their valuesExperience post-traumatic growth Cover Praise Title Page Publisher’s Note Dedication Contents PART ONE: What Is “Trauma-Focused ACT”? Ch.1. The Many Masks of Trauma What Is Trauma? What Is Trauma-Focused ACT? Why Use Trauma-Focused ACT? How to Use This Book EXTRA BIT Structure Adapt Everything Curiosity and Openness Ch.2. An ACT Model of Trauma A Brief Summary of ACT The Six Core Processes of ACT CONTACT WITH THE PRESENT MOMENT (BE HERE NOW) ACCEPTANCE (OPEN UP) DEFUSION (WATCH YOUR THINKING) SELF-AS-CONTEXT (THE NOTICING SELF) VALUES (KNOW WHAT MATTERS) COMMITTED ACTION (DO WHAT IT TAKES) Psychological Flexibility The ACT Triflex Two Useful Exercises Hands as Thoughts Pushing Away Paper Case Conceptualization in TFACT Part 1: Client’s Therapy Goals Part 2: Past History Part 3: Physical Barriers Part 4: Reexperiencing Trauma and Abnormal Arousal Part 5: Cognitive Fusion FUSION WITH THE PAST AND FUTURE FUSION WITH SELF-CONCEPT FUSION WITH JUDGMENTS FUSION WITH RULES AND REASONS FUSION WITH NARRATIVES, SCHEMAS, AND CORE BELIEFS Part 6: Experiential Avoidance Part 7: Loss of Contact with the Present Moment Part 8: Remoteness from Values Part 9: Unworkable Action Practice, Practice, Practice EXTRA BIT Takeaway Ch.3. Fight, Flight, Freeze, Flop The Science Behind Our Responses Fight or Flight Polyvagal Theory The “Fawn” Response Psychoeducation The Bear Metaphor The Amygdala: The Brain’s Threat Detector Neuroplasticity Acceptance and Self-Compassion EXTRA BIT Takeaway Ch.4. Keeping It Safe Setting Up Sessions Seating Arrangements Therapeutic Relationship Therapist Self-Disclosure Informed Consent Press Pause The Freedom to Say No Trauma-Sensitive Mindfulness Defining Mindfulness Alternative Terms to “Mindfulness” Mindfulness Meditation BREATH AND BODY EVERYTHING IS AN EXPERIMENT WHAT’S THE AIM? INVITATIONS VERSUS DEMANDS BABY STEPS Six Recommendations Takeaway Ch.5. The Choice Point Introducing the Choice Point Mapping Out Away Moves Unhooking Skills Towards Moves A Note About Action Versus Outcome Summarizing A Simple Homework Task Fill in a Choice Point After the Choice Point, What Next? EXTRA BIT Takeaway Ch.6. The Journey Ahead Four Flexible Stages At What Stage Do We Begin Exposure to Traumatic Memories? Three Common Pitfalls for Practitioners 1. Fusion with Diagnosis 2. Talking About ACT Instead of Doing It 3. Practitioner Avoidance What Measures Can We Use? Takeaway PART TWO: Beginning Therapy Ch.7. Firm Foundations The Untold Story Do Clients Have to Talk About Their Trauma? Validate, Validate, Validate Checking In Strengths and Resources Establishing Therapy Goals How to Reframe Emotional Goals EMOTIONAL GOALS ARE NORMAL! THE “CATCH-ALL” GOAL FOR ACT The Horror Movie Metaphor THE ONE EXCEPTION: NUMBNESS How to Establish Overt Behavioral Goals SESSION WITH SUE: OVERT BEHAVIORAL GOALS A FEW NOTES How to “Extract” Values from Goals Barriers to Establishing Therapy Goals I DON’T CARE ABOUT ANYTHING HOPELESSNESS, NIHILISM, AND SUICIDALITY INSIGHT AND UNDERSTANDING NO GOALS AT ALL Takeaway Ch.8. Anchors Away Dropping Anchor: The Basics The ACE Formula: Acknowledge, Connect, Engage ACKNOWLEDGE YOUR INNER WORLD CONNECT WITH YOUR BODY ENGAGE IN WHAT YOU’RE DOING What Are the Aims of Dropping Anchor? Dropping Anchor Versus Distraction Does Dropping Anchor Reduce Pain? Working with Extremes of Arousal Session with Lottie: Hypoarousal Session with Jeff: Hyperarousal But I Want to Get Rid of the Storm! Do We Have to Follow the A-C-E Sequence? How Long Does Dropping Anchor Go For? Scaling Client Responses When Do We Introduce Dropping Anchor? Debriefing Modifying Modifications for Flashbacks and Intrusive Thoughts Modifications for Distractibility Modifications to Disrupt Problematic Behavior Modifications to Develop Core TFACT Skills Homework Assigning Homework Following Up on Homework DEBRIEFING TROUBLESHOOTING Where to Next? EXTRA BIT Takeaway Ch.9. Flexible Sessions A Brief Mindfulness Practice Review of Homework Setting an Agenda Working Through the Agenda The Challenge Formula Homework EXTRA BIT Takeaway PART THREE: Living in the Present Ch.10. Slipping the Shackles of Fusion What Is Fusion? Form Versus Function First Dance in the Dark, Then Lead to the Light Flexible Terminology Exploring Thoughts Identifying Themes TEACHER MODE DETECTIVE MODE Strategies Galore Notice Name Normalize Purpose TEACHER MODE DETECTIVE MODE Workability Bringing It All Together THERAPY SESSION: DEFUSION FROM DOUBT AND HOPELESSNESS THERAPY SESSION: DEFUSION FROM SELF-JUDGMENT Actively Teaching Defusion Skills Defusion Metaphors Learning How to Notice Cognitions Defusion Exercises “I’m Having the Thought That…” Naming the Theme Thanking Your Mind Clarification and Psychoeducation ACKNOWLEDGING AND ALLOWING VERSUS DISMISSING OR IGNORING BUT I WANT TO GET RID OF THESE THOUGHTS! Homework EXTRA BIT Takeaway Ch.11. Heavy Lifting Cognitive Flexibility Going Further with Defusion Observing the Flow of Thoughts Getting Out of the River “Worry Time” The Big Three: Write; Move; Expand Awareness Writing Thoughts Down PLACING THOUGHTS ON OBJECTS Physical Movement Expanding Awareness Playful Defusion Playful Visual Techniques Thoughts on Paper Computer Screen Karaoke Ball Changing Settings WORKING WITH IMAGES Playful Auditory Techniques Silly Voices Slow and Fast Singing Smartphone Apps Create Your Own Techniques Homework Defusion Likes Company EXTRA BIT Takeaway Ch.12. Leaving the Battlefield Creative Hopelessness What Have You Tried? DISTRACTION OPTING OUT THINKING SUBSTANCES AND OTHER STRATEGIES How Has It Worked? What Has It Cost? You’ve Worked Hard! How Are You Feeling? Are You Open to Something Radically Different? Dropping the Struggle EXTRA BIT Takeaway Ch.13. Making Contact, Making Room The Four As of Acceptance Tolerance and Pseudo-acceptance Emotion Dysregulation Positive Functions of “Negative” Emotions WHAT ABOUT FEAR AND ANXIETY? DO COGNITIONS CAUSE EMOTIONS? Acceptance and Exposure Graded Exposure THE THREE COMPONENTS OF AN EMOTION Values-Guided Exposure Actively Building Acceptance Skills Through Exposure RELIVE A MEMORY IMAGINE A FUTURE SCENARIO DO AVOIDED TASKS LET YOUR GUARD DOWN SET CHALLENGING GOALS URGE-EVOKING EXERCISES FEAR-EVOKING EXERCISES ANTICIPATORY ANXIETY Safety and Defusion Before Intense Experiential Work NAME the Emotion NOTICE THE SENSATIONS ACKNOWLEDGE BY NAME MAKE ROOM FOR IT Kind Hands EXPAND AWARENESS Kind Hands: Conclusion Surfing Urges and Emotions INTRODUCING THE WAVE METAPHOR BUT MY WAVES LAST FOREVER! HOW TO SURF Debriefing and Homework Catching Experiential Avoidance “In the Act” Going Further with Acceptance APPRECIATE SELF-AS-CONTEXT THINKING FLEXIBLY ABOUT EMOTIONS EXTRA BIT Takeaway Ch.14. Self-Compassion Words Matter! Self-Compassion and Secure Attachment Attachment Theory in a Nutshell Spot the Similarities Building Blocks of Self-Compassion Acknowledging Pain Opening Up Unhooking from Self-Judgment Common Humanity THE SKY PERSPECTIVE Kindness Kind Words and Actions KIND SELF-TALK KIND IMAGERY AND MEDITATION KIND SELF-TOUCH KIND DEEDS AND ACTIONS Appreciate Barriers to Self-Compassion Fusion and Getting Overwhelmed It’s Selfish, Self-Indulgent, or Weak Motivation Religious Connotations Little or No Experience of Receiving Compassion “I Don’t Deserve Kindness” Opening Old Wounds Homework EXTRA BIT Takeaway Ch.15. Knowing What Matters Bringing Values to Center Stage Gradually Getting to Values Beginning Sessions with Values Into the Spotlight Two Surefire Ways to Values Connect and Reflect Whom Do You Look Up To? Choosing Values Three Additional Paths to Values CONVERSING ABOUT MEANINGFUL ACTIVITIES MONITORING DAILY ACTIVITIES VALUES CARDS AND CHECKLISTS Barriers to Values “I Don’t Know!” Confusion with Outcome Goals Confusion with Emotional Goals Fusion with Rules Fusion with Reasons Experiential Avoidance Clarifying Motivation Homework Flavoring and Savoring EXTRA BIT Takeaway Ch.16. Doing What Works From Values to Actions Useful Questions for Goals Goals into Action Plans LONG-TERM GOALS VALUES-BASED PROBLEM SOLVING ANTICIPATING OBSTACLES Willingness MOTIVATION THE HARD BARRIERS Transcript: Therapy Session with Mark Additional Strategies for Committed Action Savoring and Appreciating Cognitive Flexibility and Committed Action REFRAMING REINTERPRETING MOTIVATIONAL SELF-TALK “I Just Don’t Know How to Do It!” Is Attention Training Needed? Setbacks Happen EXTRA BIT Takeaway Ch.17. Undermining Problematic Behavior Function Matters! Four Steps to Undermine Any Problematic Behavior Question One: What Triggers the Behavior? Experiment on Yourself Question Two: What Are the Costs and Benefits? Experiment on Yourself Question Three: What’s a Good Alternative? Experiment on Yourself Question Four: What Skills Are Needed? Experiment on Yourself EXTRA BIT Takeaway Ch.18. Overcoming Barriers, Maintaining Change The Main Barriers to Committed Action Maintaining Change: The Seven Rs Reminders Records Rewards Routines Relationships Reflecting Restructuring the Environment EXTRA BIT Takeaway Ch.19. When Things Go Wrong Backfired Experiments Drop Anchor Explore and Validate Thank the Client Apologize Clarify Create a Learning Opportunity Session Stoppers Teamwork Troubles Raising and Discussing Teamwork Troubles How Are We Contributing to Teamwork Troubles? What Can We Learn from Teamwork Troubles? Working on Ourselves A Self-Development Exercise Preparing Ourselves for a Challenging Session Compassion for Your Client EXTRA BIT Takeaway Ch.20. Compassionate, Flexible Exposure Values-Based Exposure What Do We Measure? PRESENCE SCALE CONTROL OF PHYSICAL ACTIONS (CPA) SCALE WILLINGNESS SCALE How Long Do Exercises Last? Exposure and Response Flexibility Keeping It Safe Move with the TIMES “Difficult TIMES” CREATE UNPLEASANT SENSATIONS IMAGINE YOUR GREATEST FEARS IN VIVO EXPOSURE Exposure and Panic Attacks Motivation Psychoeducation for Panic Attacks 1. HOW STRUGGLING WITH ANXIETY AMPLIFIES IT 2. WHY IT FEELS DIFFICULT TO BREATHE 3. THE SENSATIONS OF HYPERVENTILATION ARE UNPLEASANT BUT HARMLESS Defusion Beginning Exposure Exposure and Acceptance Can Physical Movement Be a Distraction? What About Breathing Exercises? Learning Outcomes and “Expectancy Violation” Ongoing Exposure Creating an Exposure Hierarchy Step One: Brainstorm and Rate Step Two: Specify Duration and Frequency Step Three: Check for Willingness A Note on Sexual Problems Variable Exposure EXTRA BIT Takeaway Ch.21. The Flexible Self Two Types of Intervention for Self-as-Context Metaphors for Self-as-Context Mindfulness Practices for Self-as-Context The Transcendent Self The Impoverished Self EXTRA BIT Takeaway Ch.22. Working with the Body Why Connect with the Body? 1. Vitality 2. Joy and Pleasure 3. Control over Your Actions 4. Wise Choices, Good Decisions 5. Intuition, Trust, Safety 6. Safety in Your Own Body 7. Success in Life 8. Relationships 9. Love and Intimacy Tuning In to the Body Mindful Movement and Stretching Mindful Body Scans Mindfulness of Posture Mindful Self-Touch Homework EXTRA BIT Takeaway Ch.23. Sleep, Self-Soothing, and Relaxation Sleep Self-Soothing Is Avoidance-Based Self-Soothing Bad? When Is Avoidance-Based Self-Soothing Problematic? Self-Soothing Activities When Avoidance Creeps In Relaxation Skills What About Distraction? EXTRA BIT Takeaway Ch.24. Working with Shame First Steps Purpose Workability Skill Building Psychoeducation Values Work Scrunching Emotions Takeaway Ch.25. Moral Injury Pain Versus Injury A Normal Reaction Presentations of Moral Injury How TFACT Helps with Moral Injury Stuck Not Broken Grief, Forgiveness, and Compassion for Others Meaning and Locus of Control Religion and Spirituality Takeaway Ch.26. Suicidality Risk Assessment Strategies for Addressing Suicidality Defusing from Hopelessness and Suicidal Ideation NOTICE, NAME, NORMALIZE PURPOSE WORKABILITY Using Values to Find Reasons to Live Practicing Acceptance and Self-Compassion to Handle Pain Pursuing Committed Action with an Emphasis on Problem Solving Chronic Suicidality and Relapse Takeaway Ch.27. Finding the Treasure Introducing Mindful Appreciation Brief Exercises Mindful Eating Debriefing and Homework Savoring Pleasurable Activities Appreciating People EXTRA BIT Takeaway Ch.28. Building Better Relationships Understanding What Goes Wrong in Relationships Give and Take Validation and Psychoeducation Attachment Theory ATTACHMENT STYLES ATTACHMENT STYLES CAN CHANGE WHY INCLUDE ATTACHMENT THEORY? THREE CAUTIONS Applying TFACT to Any Relationship Issue The Tools We Need The Challenge Formula But It’s Not My Fault! They Need to Change! Developing Relationship Skills Addressing Issues of Trust Defusion from the Rule “Don’t Trust!” BLIND TRUST AND MINDFUL TRUST Discover Underlying Values and Flexibly Apply Them Make Room for Pain and Respond with Kindness EXTRA BIT Takeaway PART FOUR: Healing the Past Ch.29. Supporting the “Younger You” Inner Child Imagery and Rescripting Make It Interactive Compassion for the Younger You Unpack the Exercise EXTRA BIT Takeaway Ch.30. Exposure to Memories Considerations for Formal Exposure Setting Up Safely Preempting the Mind and Writing Thoughts Down Tracking Responses and Moving with the TIMES Case Example: Extract from a Session with Beth Taking Values Breaks Checking In for Impulses to Move Continuing the Session Many Ways of Working with Memories Takeaway Ch.31. Grieving and Forgiving What Is Grief? Stages of Grief Many Ways to Grieve The Act of Grieving Complicated Grief Resentment and Forgiving Self-Forgiving Forgiving Others STAGE ONE STAGE TWO EXTRA BIT Takeaway PART FIVE: Building the Future Ch.32. The Path Ahead Values, Goals, Actions, and Obstacles Maintaining Change and Handling Setbacks Specific Plans: Safety, Relapse Prevention, and Crisis Coping Anticipating Further Trauma Ending Therapy Posttraumatic Growth EXTRA BIT Takeaway Ch.33. TFACT as a Brief Intervention The Brief Intervention Mindset The First Session What Can We Do in Just Ten Minutes? How Do We Find Ten Minutes? But My Clients Want to Talk! EXTRA BIT Takeaway Ch.34. Parting Words Failure Is Inevitable Self-Care The Joy and the Sorrow Acknowledgments APPENDIX A: Resources Free Resources Books by Russ Harris Online Training—Public and Professional Trauma-Focused ACT: Online Training The Happiness Trap Online: 8-Week Program MP3s ACT Companion: Smartphone App Values Cards Facebook Group APPENDIX B: Further Training Live Workshops in Australia Online Courses ACBS Website References About the Author Index