Session 2

This session has three goals:

 To increase client awareness of the pervasiveness of emotional control as
well as its normalcy
 To further emphasize the futility and associated costs of such control
efforts
 To introduce willingness and acceptance as alternatives to experiential
control

Outline
1. Review Homework (5 min.)
2. The Pervasiveness and Normalcy of Experiential Control (10 min.)
3. The Futility and Costs of Experiential Control (20 min.)
 Chocolate Cake Exercise
 Polygraph Metaphor
 Falling in Love Metaphor
4. Willingness as an Alternative to Experiential Control (20 min.)
 Two Scales Metaphor
 Carrying Your Depression Exercise
5. Assignment of Homework (5 min.)

Agenda
1. Review Homework
Start off this session by reviewing with your clients what additional forms of expe-
riential control they may have noticed during the week by looking over their Mood
Regulation Diary. Increasing client awareness of the pervasiveness of emotional control
is more important than the completion of the diary per se, and, if it was not filled out,
still ask you clients what additional ways of digging or pulling on the rope they may
have noticed themselves using. As illustrated in chapter 4 with the client who identified
reading as a preferred and long-standing experiential control strategy, it is not unusual
for clients to uncover methods of mood regulation to which they had previously been
­oblivious. Ask your clients to consider two basic questions about whatever is identified:

Putting It All Together: A Sample Twelve-Session Protocol   167

(1) Has it worked in the long-run? (2) If so, at what costs? The client mentioned above
responded that reading had worked quite well in regulating her mood, but it did so at the
cost of interpersonal isolation.
At this point, your clients may raise a question about whether a particular practice
or activity is a form of experiential control. For example, a client returned to his second
session questioning whether his use of antidepressants was another type of digging, despite
it not being explicitly mentioned in the metaphor. In such instances, raise the same two
questions as posed above as long as there is no pressure to answer the client’s question(s)
immediately.

2. The Pervasiveness and Normalcy of Experiential Control

For your clients to sufficiently abandon the control agenda and be open to willing-
ness as an alternative, they need to see the different forms that their control agenda can
take. Clients, in effect, can’t be expected to drop the shovel if they don’t recognize the
many subtle ways in which digging can occur. While it is also useful to sensitize them to
the costs of pursuing the control agenda, suggesting that doing so is somehow abnormal
does not appear to be helpful. Thus, your task at this point in the session is to emphasize
to your clients both the pervasiveness and the dysfunctionality of experiential control, as
well as its normalcy, by saying something like the following:

We’ve now had a chance to look at some of the different ways that you try to
regulate your mood and control how you feel emotionally. We can compare
it to digging [or tugging on a rope], but for right now let’s just refer to it as
emotional control—the tendency we all have to deliberately run away from
unpleasant feelings and thoughts and to run toward ones we like.
   We all make conscious, deliberate efforts and create plans that we follow in
order to control things we don’t like. Let’s take a broader look at how those work.
For example, suppose you didn’t like the way the furniture and other furnishings
in this room are arranged. Could you do anything about it? If I offered you a
thousand dollars to rearrange the furniture in this room, could you do it? What
if instead of furniture, what you try to rearrange is how you think and feel
about something? For instance, what if you take your thoughts and feelings about
[mention some personal event from the client’s life story, linked to depression]
and try to arrange them so they’re no longer depressing to you?
   How well does that work? Could you rearrange them for a thousand dollars?
   Here’s what I’ d like you to consider—the possibility that the control agenda
that works so well in the world outside of ourselves, like the world of furniture,
doesn’t work when we try to apply it to the world inside of ourselves, to the world
of our own thoughts and feelings. What if it’s the case that the operative rule
about the outside world is “ if you don’t like something, just change it,” but the
operative rule about our own thoughts and feelings is “ if you’re not willing to
have them, you’ve got them”?
   I’m not asking you to believe me—maybe it seems to you that it shouldn’t
be this way, and that it’s not fair—but instead what does your own experience
tell you about the way it is?

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 At about this point, shift to an emphasis on the normalcy of the control agenda.
Doing so helps minimize client self-blame and, perhaps more importantly, also validates
your client’s struggles and suffering and helps build an empathetic bond between the
two of you. Point out that all of us engage in experiential control for several reasons: (1)
effective external control generalizes to emotional control, (2) others may have suggested
it should work for us (“just cheer up!”), (3) it often appears to work for others, and (4)
it may even work for us in the short-term. Further normalize experiential control by
­referring back to the Person in the Hole Metaphor.

So it’s no wonder you’ve been digging, and, as you say, you haven’t known what
else to do. Quite likely most, if not all of us—including myself—have done
and would do exactly as you have done. We all have our own holes. The only
advantage I have so I can help you with yours is one of perspective—that is,
whatever hole I may be in is not the same hole as the one you’re in.

3. The Futility and Costs of Experiential Control

You may find, however, some danger in normalizing experiential control. Some of
your clients may see this as minimizing its costs or even as providing some immunity
from blame and/or the consequences of not acting in a “response-able” manner. Address
this by further emphasizing both the futility and dysfunctionality of the experiential
control agenda through a series of related exercises and metaphors.

Chocolate Cake Exercise. To illustrate the futility of thought suppression, ask your
clients to deliberately “not think” of a particular object. The original exercise presented
by Hayes et al. (1999, pp. 124–125) used chocolate cake (and thus the origin of its name),
although other objects can be used. Hayes and Smith (2005, pp. 24–25), for example,
used a yellow jeep in their version of the exercise, and I personally prefer jelly donuts in
presenting it.

If you’re willing to do so, I’ d like to have you participate in a little exercise with
me. Whatever you do right now, don’t think of jelly donuts! You can think of
anything as long as it’s not a jelly donut. You know the kind of jelly donuts that
are soft and sweet smelling so that when put them into your mouth and bite into
them, the jelly squirts out into your mouth and is all sticky and sweet-tasting.
Don’t think about them! You can think of anything else, but whatever you do,
don’t think about jelly donuts.

Afterward, underscore the similarity between the exercise and spontaneous attempts
by your clients to suppress unwanted thoughts.

Instead of jelly donuts, suppose it’s important that you don’t think about how
you may have messed up your life. And so you tell yourself not to think about
mistakes you may have made. How well has that worked for you?

Polygraph Metaphor. Extend the futility of the experiential control agenda to efforts
to avoid unwanted emotions by presenting the Polygraph Metaphor (Hayes et al., 1999,
pp. 123–124).

Putting It All Together: A Sample Twelve-Session Protocol   169

Therapist: Let’s see how trying to control not what you think but how you feel
works. Imagine a situation in which it becomes very important that you
not feel anxious. Suppose I have you hooked up to the world’s most
sensitive polygraph and in such a way that both of us can see its findings
as the pen moves across the paper. Your task is very simple—just remain
relaxed. To impress upon you how critical it is for you not to become
anxious and to help motivate you not to be anxious, I also have a loaded
.44 that I tell you I will use to shoot you if you become anxious. How
well would you do on the task?

Client: You might as well just shoot me right now and get it over with.

Therapist: So you couldn’t stay relaxed under those circumstances. Could anyone?

Client: Certainly no one I know.

Therapist: So anyone in that situation—you, me, the average guy on the street—
couldn’t stay relaxed. Anxiety itself has now become something to be
anxious about, and if you’re not willing to have it, you’ve got it. So you’re
now anxious about being anxious. Let’s see how this might work with
depression. You’ve told me when you’re depressed, you’ve tried to cheer
yourself up. How has that worked?

Client: Not very well.

Therapist: What’s more depressing than trying not to feel depressed and failing?
Now suppose instead of not feeling anxious, your task is one of not
moving the furniture in this room and I told you I would shoot you if
you did? What would happen?

Client: I could do that.

Falling in Love Metaphor. Because experiential control in depression can also take the
form of clients deliberately trying to induce certain desirable emotional states, such as
“feeling happy” or “good about myself,” offer the following metaphor as well:

Therapist: Sometimes the way we try to control emotions we don’t like is to create
and hold on to their opposites. So, for example, instead of trying to avoid
feeling unhappy and depressed, we try to find and capture happiness. Let’s
take a closer look at how this works. Suppose I have a million dollars, and
I tell you that what you need to do to earn it is quite simple. We will leave
the office here, and all you have to do is fall madly in love with the first
stranger you see, regardless of their gender, age, or physical appearance.
Could you do it?

Client: I could sure tell you that I have.

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Therapist: But could you do it? Suppose I had some fancy machine I could hook you
up to that would tell us if you were madly in love with the first person
you meet. What would we find?

Client: That I was just saying I was madly in love with them.

Therapist: So doesn’t it seem to be the case that deliberately trying to create certain
emotions doesn’t work any better than trying to get rid of certain feelings?
Don’t take my word for it. Look at your own experience. Now notice
what would happen if I said, “Okay, you don’t have to actually fall madly
in love with the first stranger you see, but you have to run up to them
and profess your passionate love for them.” Could you do that? Would
you do that?

Client: For a million bucks, sure.

Therapist: So you can’t control how you feel, but you can control how you move
your mouth and feet.

4. Willingness as an Alternative to Experiential Control

At about this point, introduce acceptance and willingness as alternative ways of
responding to unwanted thoughts and feelings. This is also a good time to further under-
score the costs of emotional control by introducing an experiential exercise discussed in
chapter 6 for distinguishing between clean and dirty pain.

Two Scales Metaphor. This metaphor was originally presented by Hayes (1987, pp.
352–353) and subsequently further developed by Hayes et al. (1999, pp. 133–134) as
a means of suggesting to clients an alternative to the experiential control agenda. It is
­modified here slightly to be more specific to depression.

Imagine that we have before us a piece of electronic equipment—like an

amplifier for a stereo system—only this particular piece of equipment is like
a depression amplifier.
   How much depression comes out of your speakers will depend upon
where you set the knobs on the equipment. Suppose one of the knobs is
labeled “Depression” and ranges from 1 to 10. What brought you in to
therapy is that there is too much depression coming out of your speakers, and
so it makes perfectly good sense to try to adjust the depression knob. Maybe
it’s been at a 10, and you want to lower it to a 1 or 2.
   And so you’ve grabbed hold of the depression knob, and you’ve been
trying as hard as you can to change its setting. But it hasn’t worked, or you
wouldn’t be here. Furthermore, it will never work, and I don’t have some
new technique of resetting the knob to change the volume of the depression
coming out of your speakers. Now suppose there is another knob on the
amplifier and another option.

Putting It All Together: A Sample Twelve-Session Protocol   171

    This other knob is smaller, so it’s easy to overlook. We’ve been working
our way up until now to shifting our attention to it. This other knob is
labeled “Willingness.” It also ranges from 1 to 10, and as it turns out, it is
really the more important of the two. This is because, unlike the depression
knob, you can freely choose its setting. It takes no effort to change it from a
lower setting to a higher setting, but here’s the difference that it makes. Right
now your willingness knob has been set low, let’s say at a 1. Willingness
refers to how open you are to experiencing your own thoughts, feelings,
memories, bodily sensations, impulses, and the like when you experience
them, without trying to control or run away from them. What happens
when willingness is set low is that any background sadness, disappointment,
or negative thoughts that just emerge from leading a full and valued
life—what we call in ACT clean pain—get amplified into the loud noise of
depression, or what we call dirty pain. If you’re not willing to have it, you’ve
got it, and you end up being depressed about being depressed. Consider what
might happen if the willingness knob is set at a 10. Now any unwanted
sounds coming out of the speakers will not be artificially amplified. Notice
I didn’t say all of the unwanted sounds would be lowered to the level
you want or that they would go away entirely. They may still sound like
depression to you from time to time. The point is that those sounds are now
free to move rather than being locked in at a high level when all of the focus
is on lowering the depression knob. If the willingness knob is set at a higher
level, sometimes the unwanted sounds will decrease in volume and sometimes
they will increase. You can’t control their volume—all you can control is
where you set the willingness knob. Are you open at this point to explore how
your life might be different if we shift focus to changing the willingness knob
instead of the depression knob?

Carrying Your Depression Exercise. Immediately following this metaphor, present

the Carrying Your Depression Exercise detailed in chapter 6. This exercise further under-
scores the costs of experiential control by clarifying the distinction between clean and
dirty pain. Recall that this exercise uses a physical prop (such as a heavy, metal trash can)
to illustrate to clients the difference in carrying their depression in an accepting versus
avoidant manner.

5. Assignment of Homework
Also discussed in chapter 6 was the Thoughts on Cards Exercise. For homework,
provide your clients with a deck of index cards on which they are asked to write down
(one per card) unwanted, depressing thoughts that they encounter during the week.
Instruct your clients to note on the back of each card any ways they attempted to control
the thought or emotions related to it. Model the assignment by selecting a negative auto-
matic thought expressed by the client in session. Use the completed cards to begin some
defusion exercises at the beginning of the next session.

172   ACT for Depression