01 Conceptualización y Evaluación (2)

8/13/2019 01 Conceptualizacin y Evaluacin (2)

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Mindfulness- andAcceptance-Based Behavioral

Therapiesin Practice


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T! "#$L%OR&

PR!SS 'e( )or*London


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O N E

An Acceptance-Based Behavioral

+onceptualization of +linicalProblems

Ma,a a collee student came to therap, because she (as e/periencin

intense an/iet, that (as ma*in it difficult for her to et her school

assinments done and ta*e e/ams. She reported (orr,in that she


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&efinin this underl,in model is critical because the model serves as the

foundation for an individualized formulation of a particular client4sdifficulties. The model also

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6 M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B!A9$ORAL T!RAP$!S $'

provides a startin point from (hich (e choose specific assessment

strateies and clinical methods and a touchstone to (hich (e return

repeatedl, to evaluate the course and proress of therap,.

The model contains three main elements each of (hich relates to the

others. %irst clinical problems are seen as stemmin from the (a, that

clients :and humans in eneral; often relate to their internal experiences.

This relationship can be characterized as 0fused1 :a,es Strosahl < 2ilson

6===; entanled :"ermer >??@; or 0hoo*ed1 :+hodron >??7; and is

distinuished b, an overidentification (ith one4s thouhts feelins

imaes and sensations. $n other (ords ever,one feels sad from time to

time but a client (ho is fused (ith her internal e/perience ma, define

herself b, that sadness5 for e/ample Ma,a defines herself as 0(ea*1 due

to her an/iet,. This overidentification or fusion (ith internal e/periences

can set off a cascade of problematic responses. An/iet, is no loner

vie(ed as a natural emotion that ebbs and flo(s5 instead it is seen as a

definin or all-encompassin state (hich can lead to it bein uded and

vie(ed as intolerable and unacceptable. The second element of the model is

experiential avoidance or emotional conitive and behavioral efforts to

avoid or escape distressin thouhts feelins memories and sensations

:a,es 2ilson "ifford %ollette < Strosahl 6==;. +lients enae in

e/periential avoidance hopin to improve their lives but it often

parado/icall, leads to further distress or diminished 3ualit, of life :e..

a,es et al. 6==;. !/periential avoidance is closel, tied to the (a,s clients


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+onceptualization of +linical 6

elements of these approaches as (ell as traditional conitive-behavioral

approaches to hihliht (hat (e consider the central elements of an

acceptance-based behavioral conceptualization :>; briefl, revie( some of

the research that supports this model and :E; illustrate ho(


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> M$'&%#L'!SS- A'& A++!PTA'+!-BAS!& B!A9$ORAL T!RAP$!S $'

this model can be applied to specific clinical problems. 2e conclude (ith

an overvie( of ho( this model translates into intervention and continue in

the ne/t t(o chapters (ith discussion of ho( this model uides individual

treatment plannin assessment and deliver,.

Our approach to understandin problematic clinical behaviors is based

in a behavioral conceptualization. That is (e understand responses to be

learned throuh both associations and conse3uences and (e (or* to

identif, the function of problematic responses to determine strateies for

intervention. 2e see human difficulties as arisin from a combination of

bioloical predispositions environmental factors and learned habits that

lead to a host of reactions and behaviors that occur automaticall, (ithout

a(areness or apparent choice. Learnin happens in several (a,s. 2e can

learn throuh direct experience. %or instance a (oman (ho (as raped

miht learn an association bet(een the smell of specific colone and

daner (hich motivates her to avoid others (ith that same scent. 2e also

learn throuh conse3uences that consistentl, follo( particular behaviors

either reinforcin or punishin them and thus alterin their fre3uenc, as

(hen an individual continues to drin* e/cessivel, because of the stress-

relievin properties of alcohol. Learnin also occurs throuh modeling and

observation such as seein the reactions and behaviors of our parents or

siblins and throuh instruction such as bein told to act in certain (a,s or

not to sho( certain emotions. These learned patterns of behaviors often

serve a useful function particularl, in the short term5 ho(- ever as conte/ts


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+onceptualization of +linical >

impulsivel, and automaticall, enain in actions that are not valued due

to their e/perientiall, avoidant function; is thouht to contribute to distress

and diminish 3ualit, of life.


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RESTRICTED, ENTANGLED, FUSED INTERNAL

AWARENESS Limits in Internal AwarenessMan, clinical theories hihliht the potential role of deficits in internal or

e/periential a(areness in ps,choloical difficulties and the role of

increased a(areness in promot- in ps,choloical (ell-bein.6 +onsistent

(ith these models from an acceptance-based behavioral perspective

deficits in a(areness ma, manifest in several (a,s that indicate clinical

problems :these different (a,s ma, co-occur in the same individual;. %irst

clients are often unaware of their internal e/periences not reconizin

emotional conitive or ph,sioloical responses that precede problematic

behaviors :e.. ale/ith,mia;. +lients ma, also misunderstand their internal

responses labelin ph,sioloical sensations as huner (hen the, in fact

reflect distress or mista*in one threatenin emotion :such as an/iet,; for

another more personall, acceptable one :such as aner;. &imin- ished or

inaccurate a(areness reduces clients4 abilit, to use their emotional

responses functionall, and ma, lead them to react in (a,s that are puzzlin

to them. %or instance a chronicall, lonel, client ma, tell ,ou that he does

not attend social events because he does not eno, them (hen in fact he

is avoidin them due to his unreconized an/iet, and (ould ver, much li*e

to be more sociall, enaed. Another client ma, surprise herself b,

respondin aressivel, to a co(or*er because she did not realize she had

felt resentment and aner due to her co(or*er 4s repeated apparent


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+onceptualization of +linical >6 &arren olo(*a in his dissertation suests that e/periential a(areness ma, be a common

factor across diverse forms of ps,chotherap, :olo(*a >??85 olo(*a < Roemer >??7;.


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neative mood state5 ho(ever this a(areness differs sinificantl, from thea(areness that ps,chotherap, aims to cultivate. %irst this a(areness ma,

not be clear in that individuals ma, perceive the, are enerall, distressedbut not be able to pinpoint specific and subtle shifts in their emotionalph,sioloical or conitive state. %or instance a client miht describe apanic attac* that lasted > (ee*s :(hich is not ph,sioloicall, possible; orfeelin 0bad1 (ithout a clear sense of (hether he feels sadness anerfear or a blended emotion. $ndividuals4 a(areness ma, be critical

!udgmental or reactive. %or instance a client (ith recurrent depressiveepisodes miht notice her sadness and be ver, distressed that she is sad

aain thin* her sadness is a sin that a debilitatin depression is returninand feel alarmed b, its occurrence. These reactions li*el, perpetuate and(orsen the sadness possibl, leadin to depression rather than promotinadaptive functionin. Ma,a provides an e/ample of this *ind of 3ualit, ofa(areness. She (as ver, a(are of an, sins of an/iet, and responded tothem (ith self-udment and criticism further perpetuatin her an/iet,.A(areness can also become narrowed or selective. %or instance individuals(ith an/iet, disorders ma, be so a(are of a potential threat that the, donot notice other cues in their environment that sinal safet, or the, ma, be

so focused on their an/ious respondin that the, do not detect theoccurrence of positive emotional responses. This selective attention toan/iet, further e/acerbates their sense that their an/iet, is unchanin andpervasive.

All of these e/amples of (a,s in (hich the 3ualit, of e/perientiala(areness can be problematic can be thouht of as aspects of a larercateor, of overidenti"ication or 0"usion1 :a,es Strosahl < 2ilson 6===;or 0entanglement1 :"ermer >??@; (ith one4s internal e/perience in a (a,


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+onceptualization of +linical >>Althouh the terms "ear o" "ear and "ear o" emotion have been used in the literature these

concepts are more accuratel, labeled 0an/iet, of1 or 0distress about1 fear and other emotions

in that the, describe an anticipa- tor, or reactive process (ith a loner duration than fear

:Barlo( personal communication5 see Barlo( 6==6 for a discussion of the role of

an/iet,Dd,sth,mia in response to the e/perience of basic emotions in emotional disorders;.


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Barlo( 6==65 Bor*ovec < Sharples >??C;.E 2hile a (hole rane of

internal responses ma, naturall, come and o for all of us humans have

also developed an abilit, to respond to these e/periences in certain (a,s

that ma, lead them to become more riid 0stic*,1 or infle/ible resultin in

clinical problems. %or instance models of panic note that panic attac*s are

common across the population but onl, some people develop panic

disorder and these seem to be the individuals (ho e/perience an/ious

apprehension about future panic attac*s :Barlo( 6==6;. Relatedl,

behavioral models suest that individuals (ith panic disorder have

learned to e/perience an/iet, in response to their bodil, sensations:interoceptive conditionin5 Barlo( >??>;. This distress or apprehension

seems to be the crucial element of panic disorder and successful treat-

ments taret it directl,5 successfull, treated individuals continue to

e/perience panic sensations but no loner e/perience heihtened an/iet, in

response to these sensations. The reactive a(areness of bodil, sensations

that characterizes individuals (ith panic disorder is also narro(ed so that

the, focus solel, on arousal sensations and ma, have limited emotionala(areness. %or instance a recent stud, found that individuals (ho reported

a hih level of panic s,mptoms reported more neative emotional

responses and more emotional avoidance efforts in response to a positivel,

valanced film clip than did individuals not prone to panic :Tull < Roemer

>??7;5 thus these individuals ma, respond to all *inds of arousal s,mptoms

(ith an/iet, rather than discriminatin bet(een sources of that arousal.


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+onceptualization of +linical >

E +hristensen and Facobson :>???; note a similar process in couples. The, distinuish bet(een

initial problems :such as a difference in desired fre3uenc, of se/ual activit,; and reactive

problems :the difficulties that emere from each member of the couple4s attempts to cope (ith

this problem such as hostilit, (ithdra(al and accusation;.


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emotion conition and behavior. $ndividuals then learn to invalidate their

o(n e/perience further contributin to their d,sreulation. The presence

of a udmental self- critical stance :and the absence of self-compassion;

can be seen as a causal or maintainin factor in a (ide rane of presentin

problems :see 'eff Rude < Hir*patric* >??7 for evidence of association

bet(een self-compassion and ps,choloical (ell-bein;. %or instance (hen

individuals feel sad and become critical of their responses this neative

vie( of themselves ma, decrease their motivation to ma*e behavioral

chanes or enae full, in their lives. $ndividuals (ith social an/iet,

commonl, enae in self- udment that ma, e/acerbate their fears ofothers4 udments reduce their (illinness to enae in various actions

(hen the, ma, be uded and increase their sense of bein unsafe in the

(orld due to some *ind of personal failin. Ma,a4s criticisms of herself for

e/periencin an/iet, e/acerbate her fears that she (ill be unsuccessful

heihtenin rather than lessenin her an/iet,.

Entangled or FusedAwareness

Broadl, acceptance-based models that emphasize mindfulness hihliht a

3ualit, of a(areness that leads to sufferin and contrast it (ith a 3ualit,

of a(areness that can be more freein. Accordin to these models (e

commonl, become 0hoo*ed1 into our internal e/perience partl, b, seein


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+onceptualization of +linical >@ Mindfulness-based models similarl, note the (a,s that approachin e/ternal events b,

udin or (ishin the, (ere other(ise leads to sufferin. 2e discuss this aspect of

mindfulness in the section on behavioral constriction.


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(e ma, ta*e this as an indication of her true lastin feelins. +onversel,

(e ma, ta*e our o(n transient e/perience of aner to(ard and absence of

affection for our partner as an indication of our true feelins and fear thatthe relationship is over. 2hen (e e/perience sadness and consider

ourselves defined b, this e/perience (e can develop a stimatized sense

of ourselves as damaed. This fusion bet(een our e/perience and our

perception of realit, ma*es internal e/periences particularl, po(erful and

li*el, underlies our desire for them to be other than the, are. $f the thouht

that our partner does not reall, care about us (ere ust a thouht that

(ould arise and fall naturall, and did not necessaril, reflect realit, it (ouldnot be so aversive and distressin.B

a,es and colleaues :e.. a,es Strosahl < 2ilson 6===; have

(ritten e/ten- sivel, about the role that conitive fusion ma, pla, in

ps,choloical problems and the process throuh (hich this fusion develops.

Relational frame theor, :R%T5 a,es Barnes-olmes < Rosche >??6;

suests that humans continuall, derive relations amon events (ords

feelins e/periences and imaes as (e enae (ith our environ- mentinteract (ith others thin* observe and reason. These relations result in

internal stimuli :e.. imaes feelins thouhts memories; ta*in on the

functions of the events to (hich the, are lin*ed. That is a memor, of a

painful event can elicit the same reactions as the event itself and

thouhts and feelins can provo*e reactions comparable to the e/ternal

conte/ts (ith (hich the, have been paired. Relational learnin has an


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+onceptualization of +linical E $t is important to note that thouhts do not have to be clearl, false for de"usion or

decentering to be beneficial. 2hile models underl,in conitive therap, often suest that the

irrationalit, of thouhts is central to clinical problems acceptance-based models emphasize

the problematic nature of relatin to thouhts in a specific (a, ta*in them as unchanin

realities rather than reactions to a iven moment. $n this conte/t a fused relationship to athouht that accuratel, reflects a momentar, realit, (ould still be problematic in that it (ould

preclude a fle/ible choice-based adaptive mode of respondin.


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an, point (ould help alter the traector, and allo( for more fle/ibilit, in

behavioral respondin. Thus in this model critical neative a(areness

characterizes depression and the absence o" a more decentereddisentangled a(areness of this neative thouht process perpetuates it.

Studies have found that successful conitive therap, increases this

decenterin :Teasdale et al. >??>; suestin it ma, be an active

inredient in both conitive and acceptance-based behavioral interventions.

E#$ERIENTIAL A%OIDANCE

One of the most clinicall, relevant conse3uences of a fused entanled

relationship (ith internal e/periences is that it is li*el, to lead to riid

efforts to alter or avoid internal e/periences or experiential avoidance.

a,es Strosahl and 2ilson4s :6===; seminal (or* on the role of

e/periential avoidance in clinical problems provides an important corner-

stone for acceptance-based behavioral models. $n hihlihtin theimportance of consid- erin the function rather than the form of clinical

presentations a,es and colleaues suest that man, diverse clinical

problems can be understood as servin the function of e/periential

avoidance. Behaviors such as substance abuse and deliberate self-harm and

s,mptoms such as (orr, or rumination ma, all be strateies aimed at

alterin the form or fre3uenc, of internal e/periences :thouhts feelins


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+onceptualization of +linical E

of the behavior that preceded it. A commonl, held understandin of

e/cessive substance use provides a particularl, salient e/ample of this

process :e.. Marlatt < 2it*ie(itz >??@;. Althouh substance use can have

numerous apparent neative conse3uences in the lon term it t,picall,results in an initial mood shift that


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is e/perienced as pleasant and stress reducin. This conse3uence is hihl,

reinforcin particularl, for individuals (ho e/perience a reat deal of

distress andDor have particularl, neative reactions to their distress. Thusthe behavior is li*el, to continue althouh its lon-term conse3uences :e..

disruptions in relationships and other areas of functionin heihtened

tolerance (ithdra(al s,mptoms in the absence of use and the failure to

effectivel, process or resolve the distress that is habituall, avoided; all

perpetuate and increase distress. Similar models have been presented for

restricted eatin :e.. effner Sperr, !ifert < &et(eiler >??>; and

deliberate self-harm :+hapman "ratz < Bro(n >??;. Ma,a4s pattern ofboth binein and restrictin her eatin fits this model. She describes an

initial reduction in an/iet, (hen she eats e/cessivel, but her an/iet,

increases as she beins to (orr, about her (eiht. She then restricts her

food inta*e aain lo(erin her an/iet, but ma*in her emotionall,

vulnerable due to reduced nutrition increasin her ris* of becomin

distressed and overeatin aain.

$n addition to the natural conse3uences that serve to maintain andperpetuate e/perientiall, avoidant strateies social forces li*el, maintain

these strateies as (ell. Althouh several ps,choloical :e.. a,es

Strosahl < 2ilson 6===5 Ma, 6==; and Buddhist :e.. +hodron >??6;

theorists have noted the ubi3uit, of emotional pain (e often et the

messae from other people that (e should be able to control our emotional

distress throuh sheer (illpo(er. Also it can seem to us that others are


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future; ma, in part function to reduce ph,sioloical arousal. Althouh (orr,

itself is a troublin internal e/perience that individuals often (ant to et rid

of studies have sho(n that (orr, actuall, serves a positive function b,

reducin ph,sioloical arousal in response to fearful imaes or situations:e.. Bor*ovec < u 6==?;. This neativel, reinforcin


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propert, of (orr, increases its fre3uenc,. People are li*el, to *eep

(orr,in because it has this relievin ph,sioloical effect even if the, are

una(are of that effect. o(- ever (orr, also perpetuates threateninassociations b, interferin (ith the complete processin of feared events.

Someone (ho is an/ious about socializin (ith co(or*ers at lunch ma,

decrease her arousal in this situation if she is preoccupied throuhout lunch

b, her (orries about an upcomin dental appointment but this prevents her

from learnin that althouh socializin (ith colleaues can elicit some

feelins of fear it can also be pleasant and fearful feelins diminish over

time. Ruminative processes in depressed individuals ma, serve a similarfunction reducin deeper levels of sadness and pain but maintainin

eneralized neative mood states.

+lients (ith a rane of clinical problems also enae more purposefull,

in efforts to avoid internal e/periences. %or instance individuals (ith

obsessiveJcompulsive disorder describe their conitive rituals as a

strate, that reduces distress in the moment but the impairin an/iet, and

fear is maintained over time. +lients (ith posttraumatic stress disorderattempt to avoid thouhts feelins and memories associated (ith the

traumas the, have e/perienced. Althouh the, ma, ain some short-term

relief from these efforts the, find that the recollections return repeatedl,

perhaps more often because of these efforts to push them a(a,.

$ndividuals (ith substance dependence or abuse problems tr, to inore

thouhts and ures to use onl, to find them returnin more stronl,.


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model because riid efforts at e/periential control appear to have a host of

clinicall, relevant conse- 3uences suestin it is a useful taret for

intervention. Before describin these conse- 3uences in more detail it is

important to note that in certain conte/ts efforts to modif, internale/perience ma, not be problematic or harmful. #nfortunatel, the apparent

success of these strateies can fuel and maintain maladaptive efforts at

internal control.


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S*illful application of acceptance-based behavioral therap, relies on a clear

understandin of the comple/ities of e/periential control and the conte/ts

in (hich tr,in to influ- ence our internal e/periences miht be beneficialversus harmful.

$n man, cases efforts to modulate our internal e/periences can be

beneficial. %or instance (e miht focus on our breathin prior to a public

spea*in enaement and find it reduces our heart rate slihtl, allo(in us

to present material more effectivel, to our audience. On the other hand

this focused breathin ma, have no effect on our heart rate or even

increase it. 2e miht find that (e *eep thin*in about a mista*e (e madeat (or* or somethin (e (ish (e had not said to a friend and choose to turn

our attention to a movie or a boo* in an effort to reduce our rumination. This

distraction miht lead to some relief or (e miht find that our minds return

to the event repeatedl, reard- less of (hat (e tr, to brin our attention

to. $f (e are able to allo( for the possibilit, of any of these conse3uences of

our behavior there is no harm in enain in actions that miht modulate

or alter our internal e/periences. 2hen the, (or* the, miht allo( us toe/pand our a(areness ain additional perspectives have ne( e/periences

and increase fle/ibilit,. $f (e can accept it (hen the, do not (or* (e can

continue livin our lives (ith the internal e/periences (e (ere unable to

alter.

Problems can arise (hen (e bein to tr, riidl, to eliminate or avoid

distressin internal e/periences and (hen this oal becomes a prominent


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e/pressions :%oa Ris Massie < )arczo(er 6==@; and those (ho report

hiher subective an/iet, ratins :reflectin hiher emotional enae- ment5

Fa,co/ %oa < Morral 6==8; in the first session of e/posure therap, achieve

better results from such treatment. Avoidance or distraction inhibits thisne( learnin of non- fearful associations. Thus e/periential avoidance is

li*el, to maintain distress rather


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than allo( emotional responses to run their course and ne( learnin to

evolve. Ma,a4s pervasive an/iet, ma, result in part from her repeated

efforts to suppress or limit her an/ious e/perience (hich li*el, interfere(ith the natural ebb and flo( of her an/ious and fearful respondin so that

she does not e/perience the natural decline that (ould accompan,

continued e/posure to threat cues.

!/periential avoidance can also interfere (ith other aspects of the

functional value of emotional responses. !motions provide important

information reardin our interac- tion (ith our environment tellin us

(hen our needs are bein th(arted (hen a threat is present or (hen (ehave lost somethin of value :e.. %rida 6=85 "reenber < Safran 6=875

Linehan 6==Ea 6==Eb;. Our emotional responses help us communicate our

needs to others in the form of e/pressions that occur rapidl, and

automaticall,. abit- ual riid avoidance of our emotional responses is

li*el, to interfere (ith our understandin of our interactions (ith others as

(ell as of our o(n needs and desires. %or instance a client (ho is avoidin

his chronic feelins of sadness and disappointment b, distractin himself(ith alcohol miht be missin the information this sadness can provide him

such as his dissatisfaction (ith his current ob and a need to e/plore (a,s to

improve this situation or pursue another ob. Similarl, Ma,a4s constant

focus on her (or* is *eepin her from noticin the sadness and loneliness

that miht motivate her to cultivate her social and familial relationships.

!/periential avoidance can also affect our udments of or reactions to


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+onceptualization of +linical C

the clarit, of one4s internal a(areness ma*in it harder to respond

effectivel,. %or instance if Ma,a becomes anr, at her parents after the,

ma*e critical comments about her school performance but is uncom-

fortable (ith her aner she ma, onl, briefl, note her reaction and thenshift her atten-


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tion to(ard internal and e/ternal efforts to avoid this e/perience of aner.

As a result she (ill li*el, continue to feel activated and reactive in some

(a, but she ma, no loner be a(are of (hat prompted this reaction. Shema, misinterpret her response as more an/iet, (hich could hinder her

abilit, to chane the situation that elicited her aner. Thus reduced

limited or 0mudd,1 internal a(areness ma, be a result of habitual

e/periential avoidance.

%inall, e/periential avoidance often leads to behavioral avoidance or

behavioral enaement that interferes (ith individuals4 broader functionin.

$n addition to the more obvious costs :behaviors such as substance useovereatin or self-harm; e/periential avoidance can subtl, impact

behavior b, preventin individuals from enain full, in their relationships

pursuin careers (ith meanin to them or effectivel, deal- in (ith

stressful life conte/ts. Aain riidit, is the central problemGefforts to

reduce distress ma, promote functionin in man, conte/ts but riid

avoidance efforts at the e/pense of life-enhancin oals ma, lead to

restricted unsatisf,in lives.

+EA%IORAL CONSTRICTION -FAILURE TO ENGAGE IN %ALUEDACTION


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that althouh clients feel the pain associated (ith their restricted lives

the, are not a(are of the role the, pla, in perpetuatin it.

Sometimes avoidance is evident in the 3ualit, of actions rather than

their occurrence. %or instance in our (or* (ith clients (ith eneralizedan/iet, disorder (e have often found that the, seem to be enain in the

areas of life that matter to them :e..


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obs the, value spendin time (ith their children;. 2hen clients bein to

monitor their activities carefull, ho(ever it becomes clear that the, are

not full, present (hen the, are enain in these actions. $nstead the, are(orr,in about (hat ma, happen ne/t in another domain. Similarl, clients

ma, distract themselves or hold bac* emotionall, in certain conte/ts as a

(a, of avoidin distress from potential reection or hurt. %or instance &e/

a client (ho feared abandonment (ent throuh the motions of developin

a ne( relationship but *ept himself distant emotionall, (hen he (as (ith

his partner as a (a, of avoidin this feared outcome. This distancin could

have provo*ed separation (hich he (ould have e/perienced asabandonment confirmin his fear and reinforcin the behavior. All of these

forms of disenaement can limit clients4 satisfaction and success in

various areas further drivin e/periential avoidance and perpetuatin

distress.

Another (a, in (hich clients miht unintentionall, diminish their

satisfaction is b, appl,in the same udmental riid (a, of respondin to

e/ternal situations as the, do to their internal e/perience. Acceptance- andmindfulness-based approaches hihliht the role that udment of e/ternal

events can pla, in sufferin. Repeatedl, (ishin that thins (ere other than

the, are :e.. one4s partner (as different one4s colleaues (ere different;

can prolon distress and interfere (ith effective action. Linehan :6==Eb;

ives the e/ample of choosin to become stuc* in an anr, and frustrated

state (hen drivin behind someone (ho is oin too slo(l, in the fast lane


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clarif,in internal a(areness to counter the restricted or occluded

a(areness that individuals often e/perience. $n addition an emphasis is

placed on cultivatin a nonudmental compassionate relationship (ith

e/periences as the, arise to reduce reactivit, fear and


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udment (hich have been found to increase distress motivate e/periential

avoidance and interfere (ith functionin. %inall, this oal includes

cultivatin an e/perience of thouhts feelins and sensations as naturall,occurrin and transient and reducin an e/perience of them as indicators of

a permanent truth. %or instance Ma,a (ho habituall, e/periences

ph,sioloical sensations of an/iet, and interprets these as evidence of her

frailit, vulnerabilit, and inabilit, to cope (ould enae in a rane of

practices desined to help her notice the sensations as the, arise feel

compassion for herself for e/periencin them see them as overlearned

ph,sical sensations that elicit a rane of reactions but that do not defineher and e/pand her a(areness to notice other e/periences and

sensations that co-occur (ith an/iet, as (ell as the (a, that an/iet,-related

sensations subside over time.

Several t,pes of interventions can be used to assist in meetin this oal.

Psycho# education :described in depth in +hapter @; helps clients

understand the nature of internal e/periences :specificall, the function of

emotions; and the role that these t,pes of relationships to internal eventscan pla, in sustained distress and restrictions in their lives. Sel"#monitoring

can help enhance clients4 a(areness of their internal e/periences especiall,

the (a, these e/periences rise and fall and their connection to conte/ts and

behaviors. #nderstandin is not sufficient for chanin these

overlearned deepl, inrained relationships. Therefore sinificant time is

devoted to a rane of experiential practices that assist in cultivatin ne(


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choose responses rather than reactin. Monitorin helps clients see ho(

e/periential avoidance affects their lives and identif, earl, cues to

conte/ts in (hich to practice an acceptin rather than avoidant response.

Mindfulness- and acceptance-based practices help develop the s*ill ofacceptance increasin clients4 fle/ibilit, in the (a,s the, respond to

conte/ts that elicit intense reactions.


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%inall, ABBTs emphasize the oal of increasing valued action. This

includes refrain- in from actions that ma, be ver, temptin in the

moment :often because the, serve an e/perientiall, avoidant function; butare not in line (ith the (a, the client (ants to live his or her life and

enain in actions that matter to the individual but have been avoided.

$mportant components of this oal include identif,in and clarif,in (hat

matters to the individual brinin a(areness to moments (hen choices

could be made based on these values and enain in action in desired

directions.

All the methods that promote the first t(o oals also serve this oal inthat enain in chosen action is facilitated b, an unentanled defused

relationship to one4s e/perience and an abilit, to choose a

none/perientiall, avoidant response. $n addition ps,- choeducation and

monitorin help brin a client4s attention to (hat is important to him or her

to set the stae for chosen action. 2ritin e/ercises serve to clarif, values

as does mindfulness practice. 'onreactive decentered a(areness can allo(

one to re"lectively see (hat matters rather than re"lexively endorsinvalues based on societal pressure or fears :Shapiro +arlson Astin ??;. %inall, bet(een-session behavioral e/ercises in (hich

actions are chosen and planned for enaed in and revie(ed allo( clients

to e/pand their behavioral repertoire and enae more full, in their lives.

These behavioral chanes often elicit ne( t,pes of problematic relationships

(ith internal e/periences and impulses that promote e/periential


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Tw"

+linical Assessment of Relevant

&omains

The first step to (or*in (ith a client from an acceptance-based behavioral

perspective is to conduct a comprehensive assessment of the nature and

e/tent of the client4s presentin problems ps,choloical status attitudes

to(ard internal e/periences :e.. emotions ph,sical sensations; common

copin strateies :includin e/periential avoidance; 3ualit, of life and

previous e/perience in treatment 'ot onl, is a careful and s,stematic


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(e focus on measures (e find to be hihl, applicable :in that the, assess

constructs that are important and meaninful to the client and that uide

treatment; acceptable :brief and user-friendl,;practical :minimal

EC


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+linical Assessment of Relevant E

cost eas, to score and interpret; and psychometrically sound :reliable

valid and sensitive to chane;.

S/.$TO.0+ASED

ASSESS.ENT +r"a) O(er(iew "f $resentin1

C"ncerns

2e start the assessment process b, tr,in to et a sense of the client4s

presentin concerns desired life directions and current factors that

motivated him or her to see* treatment. T,picall, this initial report (ill

include a description of ps,choloical s,mptoms :e.. difficult,

concentratin h,perarousal; current emotional state :e.. sad an/ious

anr,; and difficulties in functionin that are impactin 3ualit, of life :e..

interpersonal conflicts problems at (or* diminished ph,sical health and

(ell-bein;. Persons :6=8=; and 2ood, and colleaues :>??E; suest that

earl, in the assessment period clinicians develop a comprehensive problem

list (hich can be used to identif, priori- tize and manae all of the client4s

current difficulties. %or e/ample &ere* initiall, presented (ith complaints

about depression includin depressed mood fatiue difficult, sleepin

decreased appetite and difficult, concentratin. e also noted that he (as

3uite irritable both at (or* and (ith his partner. is partner (as also


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FIGURE 2343 &ere*4s problem list.


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to propose an underl,in mechanism that accounts for the problems

enumerated on the problem list and tie them toether in a (a, that (ill

uide treatment.2e also ma*e an effort to learn about the client4s cultural identit,. A

culturall, sensitive approach to assessment is aimed at ensurin that the

client4s problems are accuratel, understood and defined ta*in into

account cultural norms and e/pectations informin the development of an

appropriate treatment plan that ade3uatel, meets the needs of the client

and demonstratin respect for the client4s culture in an attempt to promote

a stron therapeutic alliance :Tana*a-Matsumi Seiden < Lam6==;. The therapeutic relationship is a critical component of ABBT that is

assumed to foster an environment in (hich the client can bein to develop

a self-acceptin and self- compassionate stance. ABBTs re3uire a sinificant

commitment on the part of the client as e/tensive bet(een-session practice

(ith mindfulness and valued actions is encouraed. $n our e/perience a

stron therapeutic relationship increases enaement in and compliance

(ith therapeutic activities.As discussed in more depth in +hapter 66 understandin a client4s

cultural identit, can inform man, facets of ABBT. +ultural factors can pla,

a sinificant role in ho( one vie(s one4s emotions ho( emotions are

vie(ed b, one4s famil, members and the t,pes of values :e..

individualistic or interdependent; that are personall, held. Atten- tion to

ho( e/ternal forces such as economic disadvantae and oppression affect a


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42/72


%rom this perspective (e (elcome and e/pect clients (ho feel both

disconnected from the re(ards associated (ith ma*in a life chane and

painfull, a(are of the obstacles to ma*in this chane to present (ithambivalence. The oal of ABBT is to increase the salience of positive

re(ards of chane b, helpin clients access (hat is personall,

meaninful about their oals for treatment and decrease the size and

manitude of obstacles b, chanin the relationship clients have (ith their

internal e/periences.

Once (e have a broad overvie( of these presentin issues (e delve

deeper into the assessment process b, more s,stematicall, assessin avariet, of domains.

$s!ch"&ath"l"1!

a,es and his colleaues :6==; criticized the (idel, held medical

s,ndromal model of ps,chopatholo, citin the hih rates of comorbidit,lo( treatment utilit, and fre- 3uent irrelevance of the dianostic model to

the t,pes of presentin problems t,picall, seen in clinical practice. As an

alternative he and his colleaues proposed a dimen- sional functional

approach to ps,chopatholo, that assumes that man, forms of ps,-

chopatholo, are best conceptualized as e/periential avoidance. 2hile (e

support this perspective for a number of practical and clinicall, relevant


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There are also a number of lobal and s,mptom-specific 3uestionnaires

that can be used to provide more information about the nature and severit,

of ps,choloical s,mptoms e/perienced b, the client. The &epression

An/iet, Stress ScalesG>6-$tem 9ersion :&ASS->65 Lovibond < Lovibond6==@; is a >6-item measure that ,ields separate scores of depression

an/iet, :i.e. an/ious arousal; and stress :e.. tension;. The Brief S,mp-


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+linical Assessment of Relevant C

tom $nventor, :BS$5 &eroatis < Spencer 6=8>; can also be a useful

3uestionnaire measure for assessin overall ps,choloical distress. The BS$

provides information about a client4s s,mptom report on nine primar,s,mptom dimensions and ,ields three more lobal indices of ps,choloical

functionin.

$"tentiall! armful+eha(i"rs

!naement in self-inurious and impulsive behaviors such as deliberateself-harm :e.. cuttin burnin; substance misuse unsafe se/ual

practices and compulsive spendin amblin and eatin can be a form

of e/periential avoidance that is important to assess. %or man, clients

these behaviors are also associated (ith sinificant shame (hich means

the, are fre3uentl, underreported. $t can be clinicall, useful to routinel, as*

clients (hether or not the, use alcohol drus food or potentiall,

danerous activities as a (a, to cope (ith their emotional pain. &irectl,as*in about embarrassin and ris*, behaviors in a matter-of-fact (a,

demonstrates acceptance and validation and increases the probabilit, that

clients (ill be (illin to disclose such information.

$t can also be useful to overestimate the fre3uenc, of potentiall,

harmful behaviors durin 3uestionin to et a more accurate self-report. %or

e/ample durin a phone screenin a client named Rochelle (as as*ed


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abilit, that he (ould be rehospitalized. &urin an assessment meetin

Anel4s ne( therapist shared his vie( that people enae in all sorts of

behaviors that the, *no( are harmful because the, find their emotional

pain so intense. The therapist normalized suicidal thouhts b, suestinthat suicide often seems li*e the onl, option to someone


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(ho is in sinificant distress. e encouraed Anel to tal* openl, about his

thouhts and feelins and offered Anel the possibilit, that he could learn

ne( problem-solvin s*ills :e.. acceptance and tolerance of emotionalpain behavioral activation; throuh ABBT as an alternative to suicide.

A number of individual and situational factors should be assessed to

inform the clinician of the potential tarets for treatment to decrease

suicidalit, includin conitive st,le :e.. infle/ibilit,; problem-solvin st,le

:e.. deficit in s*ills; emotional pain and sufferin emotionall, avoidant

copin st,le interpersonal deficits self-control deficits and environmental

stress and support :+hiles < Strosahl >??@;. The Reasons for Livin$nventor, :Linehan "oodstein 'ielsen < +hiles 6=8E; can be used to

measure a rane of beliefs :social and copin beliefs responsibilit, to

famil, child-related concerns fear of suicide fear of social disapproval and

moral obections; that ma, be important in preventin a client from

attemptin suicide.

RELATIONSI$ TO INTERNAL

E#$ERIENCES Awareness "f Em"ti"nal E'&erience

A critical part of our assessment involves e/plorin the client4s

relationship to his or her internal e/periences :e.. emotions thouhts

internal sensations;. %irst (e pa, attention to the level of a(areness and

ifi i i h hi h li d ib h i i l f li


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(hen ma*in a numerical ratin.

Similarl, clients are often una(are of specific situational triers that

elicit particular emotions. Once aain individualized self-monitorin

sheets can be developed

+li i l A t f R l t C


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to better assess these domains :see %orm >.> p. @>;. %or e/ample a client

can be as*ed to notice the emerence of t(o or three stron emotions each

da,. 2hen the client e/periences one of those emotions he or she can beas*ed to note the da, and time the situation the emotion elicited and

an, accompan,in thouhts or ph,sical sensations.

2hile an intervie( and self-monitorin ma, reveal difficulties in

identif,in and describin emotions there are also 3uestionnaires that

assess this response st,le. %or instance the T(ent,-$tem Toronto

Ale/ith,mia Scale :TAS->?5 Bab, Par*er < Ta,lor

6==C; is a 3uestionnaire that measures the construct of ale/ith,mia.Ale/ith,mia is characterized b, difficulties identif,in and describin

emotions a tendenc, to minimize emotional e/perience and a pattern of

focusin attention e/ternall,. $tems such as 0$ am often confused about

(hat emotion $ am feelin1 and 0$ often don4t *no( (h, $ am anr,1 are

rated on a @-point scale ranin from 6 :0stronl, disaree1; to @ :0stronl,

aree1;. The TAS->? ,ields an overall score and scores for three subscales

&ifficult, &escribin %eelins &ifficult, $dentif,in %eelins and !/ternall,Oriented Thin*in.

The &ifficulties in !motion Reulation Scale :&!RS5 "ratz < Roemer

>??C; is a

E-item measure that can provide comprehensive information about

various aspects of

a client4s emotion reulation :discussed in more depth belo(;. T(o

C M$'&%#L'!SS A'& A++!PTA'+! BAS!& B!A9$ORAL T!RAP$!S $'


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rated on a

-point scale ranin from 0almost al(a,s1 to 0almost never.1 2hile this

measure is

helpful in assessin a(areness it does not tap into man, of the other

important ele-

ments of

mindfulness.

Several other measures of mindfulness are desined to capture more of

its facets.

%or instance the %reibur Mindfulness $nventor, :%M$5 Bucheld "rossman

< 2alach

>??6; is a E?-item 3uestionnaire that assesses nonudmental present-

moment obser-

vation and openness to neative e/periences. The Hentuc*, $nventor, of

Mindfulness

S*ills :H$MS5 Baer Smith < Allen >??C; is a recentl, developed E=-item

scale desined



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to measure four of the five aspects of mindfulness described above

observation description actin (ith a(areness and acceptin (ithout

udment. There is also pre- liminar, support for the development of a E=-item measure the %ive %acet Mindfulness Nuestionnaire :%%MN5 Baer et al.

>??; (hich includes items from all of the measures described above.

Fusi"n with InternalE'&eriences

The model drivin ABBT proposes that bein fused (ith or hoo*ed b, ,ourinternal e/periences drives attempts at e/periential avoidance. Thus one of

the oals of therap, is to help clients decenter or defuse from their

thouhts emotions imaes and ph,sical sensations. One potentiall,

useful (a, to assess an individual4s fusion (ith his or her o(n thouhts

and feelins is to as* him or her to rate the believabilit, of different

thouhts and internal e/periences that arise. 2hile there are no eneral

measures to assess this construct researchers have developed content-specific measures that as* individuals to rate the believabilit, of the content

of depressive thouhts :Iettle < a,es 6=87; hallucinations and delusions

:Bach < a,es >??>; and stimatizin attitudes :a,es Bissett et al.

>??C;.

The ThouhtJAction %usion Scale :TA%S5 Shafran Thordarson ??@;.

There are several methods one can use to assess sleep 3ualit,. ThePittsburh Sleep Nualit, $nde/ :PSN$5 Bu,sse Re,nolds Mon* Berman ;. $n addition to

these 3uestionnaire measures a sleep diar, in (hich participants self-

monitor their dail, sleepD(a*e patterns has been sho(n to be a reliable

assessment instrument :Roers +aruso < Aldrich 6==E;.&iet and e/ercise are also important components of 3ualit, of life (orth

assessin. !ven (hen eatin concerns are not a presentin problem poor

nutrition and erratic eatin patterns can threaten a client4s health and (ell-

bein. Se/ual functionin is often overloo*ed as a component of 3ualit, of

life. A lare epidemioloical surve, conducted in the #nited States

:Laumann Pai* < Rosen 6===; found that CE of female and E6 of male

respondents e/perienced some form of se/ual d,sfunction. Problems inse/ual functionin can neativel, impact mood and strain intimate

relationships. Althouh man, clients are uncomfortable discussin their

se/ualit, (e have found that it can be 3uite normalizin to as* about

satisfaction in this important life domain as part of a comprehensive

assessment of 3ualit, of life. %urthermore a 3uestionnaire such as the

&eroatis Se/ual %unctionin $nventor, :&S%$5 &eroatis < Melisaratos


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currentl, out of (or* on disabilit, due to s,mptoms of M&& and (ho hihl,

values bein challened and contributin in the (or*- place miht rate this

domain as hihl, valued and inconsistentl, pursued. +lients (ith this profile

are li*el, to report sinificant ps,choloical distress and to appear immobi-lized (ith reard to movin for(ard and ma*in chanes in valued domains.


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Another pattern (orth notin is one of e/tremel, lo( importance scores

across most or all valued domains. %or instance a client (ho is e/tremel,

isolated (ith a histor, of social reection miht uniforml, rate famil,intimate relations parentin and friendship as all unimportant. Sometimes

this pattern of 0not carin1 ma, actuall, reflect a desire to avoid the pain

associated (ith ac*no(ledin a (ish to be connected (ith others :2ilson

< Murrell >??C;. $n these cases the clinician can entl, e/plore if 0not

carin1 is preventin the client from pursuin these important life domains.

A final notable pattern is that of e/tremel, hih total importance and

consistenc, scores. Particularl, (hen a client reports little ps,choloicaldistress such endorse- ment ma, reflect the client4s desire to present him-

or herself in a sociall, acceptable (a, :2ilson < Murrell >??C;. $n our o(n

practice (e have seen a number of clients (ho endorse man, values as

hihl, important and report that the, are consistentl, actin in

accordance (ith these values but describe sinificant ps,choloical

distress. $n these cases clients are often 0oin throuh the motions1 of

livin a valued life (ithout brinin mindfulness to their e/periences. %ore/ample 2end, (as a professional (ith an e/citin and challenin career

a solid marriae and three (onderful children. On the surface she seemed

to be stri*in a balance bet(een succeedin in her career and spendin

3ualit, time (ith her famil,5 ho(ever upon more careful intervie(in it

became apparent that 2end, (as not brinin mindfulness and intention to

her behavior in valued domains. 2hen she (as at (or* althouh her


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the, are as*ed to thin* about (hat it means be a ood friend and iven

possible descriptions to consider such as bein supportive considerate

carin acceptin lo,al or honest; and then as*ed to articulate an,

personal values the, ma, have in this domain. 'e/t clients are presented(ith nine 3uestions about the value each rated on a @-point scale that

assess motiva-


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tion for holdin the value the e/tent to (hich behavior is currentl,

consistent (ith the value commitment to the value importance of the

value and (hether or not it is a potential area for improvement.Lundren &ahl and a,es :>??8; have developed the 9alues Bull4s

!,e a measure of values attainment and persistence (hen encounterin

barriers usin a series of four pictorial representations of dartboards. The

first three dartboards are used to assess the e/tent to (hich clients are

livin consistent (ith their values. The client is as*ed to describe three

deepl, held personall, relevant valued directions that he or she (ould li*e

to (or* on in therap,. The center of the dartboard :the bull4s e,e;represents livin full, in accord (ith that value and the client is as*ed to

mar* ho( close to the bull4s e,e he or she is currentl, livin. A fourth

dartboard is used to assess persistence of actin in accordance (ith values

in the face of ps,choloical barriers such as an/iet, or sadness. The client is

as*ed to (rite do(n individual barriers that ma*e it difficult to live consis-

tent (ith his or her values then to indicate persistence of valued action in

the face of the described barriers :(ith the bull4s e,e meanin the client

al(a,s persists;. The distance bet(een the center :bull4s e,e; and the ede

of all four dartboards is C.@ centimeters and scores representin the

distance bet(een the mar* and the bull4s e,e can var, from ? to C.@ (ith

lo(er scores e3ualin reater attainment or persistence. 9alues attainment

is a mean of the first three dartboards5 persistence throuh barriers is

enerated b, the sinle measure.

h d f d ibl i h h i h


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approaches dra( from and are compatible (ith +BT techni3ues such as

self-monitorin e/posure therap, behavioral activation and s*ills trainin.

Some (a,s of approachin irrational thouhts (ith conitive restructurin

are consistent (ith the ABBT oal of chanin


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the relationship that the client has (ith his or her internal e/periences. %or

e/ample encourain a client to consider his thouhts as merel, thouhts

and not facts to attend a part, even (hen he is feelin an/ious and toobserve (hat reall, happens in that feared situation miht be part of both

approaches to treatment. $n contrast other conitive approaches ma,

focus more on chanin the content of a specific thouht in order to

decrease an/iet, (hich is less consistent (ith an ABBT perspective. %or

e/ample a client (ho is an/ious at parties ma, be as*ed to tr, and replace

the thouht 0$ feel li*e a fool because $ am not as educated as the other

people here1 (ith somethin li*e 0$ am an interestin and educatedperson.1 The rationale of +T in this case (ould be to reduce the fre3uenc,

and intensit, of uncomfortable thouhts (hich (ould be e/pected to

decrease an/iet, and facilitate e/posure to feared situations. Althouh

s,mptom reduction is an obvious oal of ABBT the emphasis in this

approach is on developin an acceptin and compassionate stance to(ard

oneself and enain in actions that are consistent (ith personall, relevant

values.

As conitive-behavioral approaches have ro(n in popularit, the term

has come to describe a much broader class of disparate techni3ues.

Therefore (e find it useful to as* our clients more specificall, about (hich

elements of +BT the, received :e.. ps,choeducation conitive

restructurin behavioral activation s*ills trainin rela/- ation trainin

e/posure therap,;. %urthermore if the, report that certain techni3ues (ere

:SA&; d h d th t t b d h t


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:SA&; and he e/pressed concern that an acceptance-based approach to

treatin his "A& s,mptoms (ith the current therapist (ould be inconsistent

(ith the (or* he had completed. 2e (ere able to dra( parallels for him

bet(een the self-monitorin he completed and the development of the

mindfulness s*ill of attention. %urthermore (e discussed the consistencies


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bet(een no loner acceptin certain thouhts as facts and the decenterin

and defusion s*ills of mindfulness. Rather than directl, confrontin Mar*

about (hether chanin the content of his thouhts (as necessar, fortreatment (e as*ed him if he (as (illin to e/pand his repertoire and tr,

some ne( approaches to cope (ith his emotions (hen conitive

restructurin (as ineffective.

N"n)irecti(eTreatment

2hile the acceptance and validation aspects of ABBT are 3uite consistent

(ith man, nondirective humanistic approaches to therap, the behavioral

elements of ABBT that re3uire sinificant out-of-session activit, are not as

common to these approaches. $t can be ver, useful for the clinician to

*no( about a client4s previous e/perience and satisfaction (ith nondirective

therapies as such a histor, can definitel, affect a client4s oals and

e/pectations for treatment. %or e/ample Richard souht treatment (ith one

of us :Orsillo; after terminatin (ith a humanistic therapist he had been

seein for appro/imatel, >? ,ears. At first Richard (as put off b, the

suestion that therap, (ould re3uire out-of-session (or* statin that he

had done home(or* (hile he (as in school and he did not see the need for

home(or* in therap,. $ spent considerable time (ith Richard in an effort to

provide an ade3uate and compellin rationale for out- of-session practice. A

therap, she and her therapist spent some time revie(in their proress


67/72

therap, she and her therapist spent some time revie(in their proress

and noted that Shoshanna (as strulin sinificantl, (ith the mindfulness

concepts of self-compassion and acceptance. Because the therapist did

not full, assess Shoshanna4s past e/perience (ith medi- tation she (as

una(are that Shoshanna had little practice (ith these s*ills.


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TA+LE 2343 A))iti"nal AssessmentRes"urces

Author:s; :,ear; %orm &omain

Reprints

measures

Anton, Orsillo< Roemer:>??6;

Boo* An/iet, )es

'ezu RonanMeado(s< Mc+lure :>???;

Boo* &epression )es

+ocoran ???;

Boo* Broad spectrum ofps,choloical constructs

)es

Association for+onte/tualBehavioral Science

2ebsite :www.contextualpsychology. org;

9ariet, of A+T-relatedassessment instrumentsincludin man, that currentl,under development

)es

Buros $nstitute ofMentalMeasurements

2ebsite:www.unl.edu'buros;

"eneral and comprehensive listin of 'ops,choloical instruments

ADDITIONAL ASSESS.ENT RESOURCES FOR TE CLINICIAN

FOR.2 4
http://www.unl/http://www.unl/http://www.unl/http://www.unl/http://www.unl/http://www.unl/http://www.unl/http://www.unl/http://www.unl/http://www.unl/


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234AN#IET/ AWARENESS SEET

Please rate ,our an/iet, :on a scale of ? to 6?? (ith ? bein no an/iet, at all

and 6?? bein severe an/iet,; at four different times durin the da,. $f ,ounotice an,thin (hile ratin ,our an/iet, feel free to ot do(n these

observations belo( the form.

Ratin1Scale- ? @? 6??

'o an/iet, atall completel,

rela/ed

Moderate an/iet, Severe an/iet,

&ate

Mornin

'oon

TimeDRati

!venin

'iht

TimeDRati

@6


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@> FOR.232

E.OTION .ONITORING SEET


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2hen ,ou notice that ,ou are e/periencin a stron emotion please ta*e a moment to notice and (rite do(n the

situation ,ou are in and the emotion ,ou are e/periencin. Please also record an, thouhts ,ou are havin at that

time and an, ph,sical sensations :e.. heart racin muscle tension fatiue;.

&ateDTime Situatio !motio Thouht Ph,sical

%rom Lizabeth Roemer and Susan M. Orsillo :>??=;. +op,riht b, The "uilford Press. Permission to photocop, this form is ranted topurchasers of this boo* for personal use onl, :see cop,riht pae for details;.

FOR.235

ASSESS.ENT OF CO$ING STRATEGIES


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@E

As ,ou have been doin please continue to notice stron emotions that emere in different situations and the

thouhts and sensations that accompan, each emotion. Also note ho( ,ou respond to the emotion :e.. pa,

attention to it tr, and push it a(a, distract ,ourself tr, and chane it etc.; and the outcome :successful

unsuccessful feel better feel (orse etc.;.

&ateDTim Situation !motionsDThouhtsDSensatio Response Outcom

%rom Lizabeth Roemer and Susan M. Orsillo :>??=;. +op,riht b, The "uilford Press. Permission to photocop, this form is ranted topurchasers of this boo* for personal use onl, :see cop,riht pae for details;.

Documents

01 Conceptualización y Evaluación (2)