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