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Section 4
Acceptance Therapy

Question 4 | Test | Table of Contents

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In the last section, we discussed successive approximations.  Successive approximations consist of setting subgoals, identifying triggers, and implementing the technique through behavior. 

In this section, we will discuss accepting reality.  Three techniques that we will discuss are gaining distance, describing the present, and disappearing to see reality.  As you read this section, consider your client.  How might you include these techniques with the therapeutic approach you are currently using?

3 Methods for Accepting Reality

♦ 1.  Gaining Distance
One way to deal with anxiety is by gaining distance.  Clearly, a client’s worries involve what he or she thinks reality is.  Because thoughts are internal experiences that change every second and are different from someone else’s thoughts, clients may need help differentiating thoughts from reality.

Gaining distance from thoughts means standing back and noticing that thoughts are simply thoughts.  How can you help your client take each of his or her worries and observe that he or she is simply having a thought? Gaining distance from thoughts can also help clients in recognizing that their thoughts have been wrong about reality. 

For example, the worry your client had about getting struck by lightning by his 23rd birthday clearly turned out to be incorrect.  In my practice, I see that clients tend to have thoughts and feelings that they thought they would always be concerned with.  Perhaps your client thought, "I will always be bothered by this" or "I will always feel this way."  A client’s thoughts and feelings change so the worry about things always being the same is a thought, a guess, a false alarm.  It is not reality.  But how can we help our anxiety clients realize this?

♦ CBT Technique: Index Card Worries
Gaining distance from thoughts also means recognizing that thoughts can be experiences that a client observes and lets go.  A technique for gaining distance that I used with Raul involved identifying his concerns.  Raul, age 47, implemented techniques discussed previously in this course to identify his anxiety triggers.  Next, Raul took a pile of index cards.  On the back of each card Raul wrote something that concerned him. Raul was Hispanic and was aware that according to the CDC, cardiovascular disease is the leading cause of death among US Hispanics.

For example, one of Raul’s worries was that he might have a heart attack.  Raul worked to try to get as many worries as he could on the back of the index cards.  When Raul felt that he had all of his concerns written down, he shuffled the deck with the worries facing away from him.  Then Raul picked up the cards one at a time, looked at each one, and tossed them into a wastepaper basket.  After Raul finished with this exercise, our session was over.  Raul got up and walked out of my office.  Later, Raul stated, "I guess gaining distance means learning how to walk away from your worries." 

♦ 2. Describing What is in Front of You
In addition to gaining distance, another way to accept reality and commit to change is to describe what is in front of you.  Do you find that your client’s worries seem to leap far beyond the information that is in front of them? 

Case Study: Haley
Haley, age 36, often found herself sitting at her desk thinking about the things on her to do list.  Haley would begin to worry.  Soon she would jump to conclusions. 

Haley stated, "Before I realize what I’m doing, I start to think I’ll never get all my work done, my boss will get angry, and I’ll get fired.  Then I start thinking about how hard it is to get another job, how I might deplete my savings and go into debt."  How might you have responded to Haley?  I stated, "Notice how these worries have nothing to do with what is right in front of you at the moment.  What is in front of you as you worry is the work you have to do."  Clearly, if Haley focuses on her work, she can avoid her other worries.  Do you have a client like Haley?  Could the following cognitive therapy intervention benefit him or her?

I asked Haley if she could describe the work she had on her desk the last time her worries overwhelmed her.  Haley stated, "Today there was a folder with some memos that were written by my boss and my colleagues."  I asked what else was there.  Haley responded, "There was a printout of data."  I then stated, "Now describe what happened.  Haley stated, "I got an email from my boss requesting a report by tomorrow morning." 

Haley then described what she had done already. "I looked over the material a few times and outlined some of the things I wanted to write up.  I reviewed the data and other reports."  After several sessions involving similar dialogue, Haley began to implement this type of thinking on her own at work.  Describing what is in front of her helped Haley stay with the facts.  Describing, rather than jumping to conclusions, allows clients like Haley to place themselves in reality as it is and keeps them from worrying about all the possible realities that may never be.  Do you have a client like Haley who could benefit from a descriptive technique?
♦ 3. Disappear to See Reality
A third method for accepting reality and committing to change is to disappear to see reality.  Perhaps you can ask your client to imagine disappearing completely.  He or she can think about what they are worried about right now.  Something has to get done, something might get out of control, some part of the world may not work exactly the way it should work.  Now, ask your client to imagine that he or she does not exist. 

They are not here.  Time and events flow on without them.  Tomorrow comes and they are not here.  The sun will still come up, people will still go to work.  The client has disappeared.  If the client has disappeared and no longer exists, then there is nothing to worry about, is there?  The people who might not have liked the client?  Well, he or she doesn’t exist, so why does it matter?  The bill that might be late?  How could he or she care, because he or she no longer exists to care?  They are no more.

♦ The Dark Side of Spirituality
Now this might sound like the dark side of spirituality, but it really is the nature of almost all reality.  I tell my clients, "There are eight billion people in the world.  How much of this space do you really occupy?  Where are you in this space of humanity - one in eight billion?  One way of getting balance about the things that you worry about is to try to remind yourself that the world is not about you."  Of course you pick and choose the type of client with which to try this technique.

♦ CBT Beach Visualization Exercise
To help the client put their concern in perspective, I continue with a visualization exercise some clients find helpful.  I state, "Imagine a vast beach that stretches for a thousand miles and is fifty miles wide.  The wind blows, and a single grain of sand falls two feet from where it used to be.  That is you.  You are a grain of sand.  You struggle against the landscape, pushing and complaining about how all the other grains of sand get in your way.  But stand back for a moment and look at the larger view.  The beach looks the same as ever."  This mental imagery helps some clients see their worries as less consequential.

Think of your client.  How could techniques for description, gaining distance, or disappearing to see reality help with anxiety?  Could playing this section at your next session be productive?

In this section, we discussed accepting reality.  Three techniques that we discussed were gaining distance, describing the present, and disappearing to see reality.

In the next section, we will discuss uncertainty training in two steps.  Step one is examining the costs and benefits of accepting uncertainty and step two is flooding with uncertainty.  We will also examine problems associated with thought stopping regarding anxiety.
Reviewed 2023

Peer-Reviewed Journal Article References:
Barreto, M., & Gaynor, S. T. (2019). A single-session of acceptance and commitment therapy for health-related behavior change: Protocol description and initial case examples. Behavior Analysis: Research and Practice, 19(1), 47–59.

Gaudiano, B. A. (2010). Evaluating acceptance and commitment therapy: An analysis of a recent critique. International Journal of Behavioral Consultation and Therapy, 5(3-4), 311–329.

McCabe, R. E. (2015). Review of The mindfulness and acceptance workbook for social anxiety and shyness: Using acceptance and commitment therapy to free yourself from fear and reclaim your life [Review of the book The mindfulness and acceptance workbook for social anxiety and shyness: Using acceptance and commitment therapy to free yourself from fear and reclaim your life, by J. E. Fleming & N. L. Kocovski]. Canadian Psychology/Psychologie canadienne, 56(1), 152–153.

Schoendorff, B., & Steinwachs, J. (2012). Using Functional Analytic Therapy to train therapists in Acceptance and Commitment Therapy, a conceptual and practical framework. International Journal of Behavioral Consultation and Therapy, 7(2-3), 135–137.

Twohig, M. P., Ong, C. W., Krafft, J., Barney, J. L., & Levin, M. E. (2019). Starting off on the right foot in acceptance and commitment therapy. Psychotherapy, 56(1), 16–20.

Zarling, A., Bannon, S., Berta, M., & Russell, D. (2020). Acceptance and commitment therapy for individuals convicted of domestic violence: 5-year follow-up and time to reoffense. Psychology of Violence, 10(6), 667–675.

What are three CBT techniques to help clients accept reality? To select and enter your answer go to Test.

Section 5
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