Table Of Contenti
Advance praise for ACT in Steps
“This manual targets a central challenge of ACT—how to move from learning
about the therapy to actually doing it—and hits its mark. It is accessible and con-
cise, offering a session-by-session guide through the therapy from beginning
to end, including initial evaluation, ongoing assessment, and between-session
homework. The authors provide just the right balance of explanation and prac-
tical how-to’s needed to set ACT novices on a solid path to competency. In short,
it is a perfect answer to, “But, how do I actually do the therapy?” For anyone inter-
ested in learning to do ACT—here is your guide.”
—Darrah Westrup, PhD, author of Advanced ACT:
An Experienced Practitioner’s Guide to Optimizing
Delivery, co-author of ACT for the Treatment of Post-Traumatic
Stress Disorder & Trauma-related problems, The Mindful Couple,
and Learning ACT for Group Treatment
“Wow! What a useful and clear guide to starting out in ACT! I wish I’d had this
book when I was an ACT newbie—would have saved me so much anxiety, con-
fusion, and self-doubt. (And it also would have saved my clients from so many of
the common beginners’ mistakes I repeatedly made!) Full of wisdom and packed
with practical strategies, I can highly recommend this book for any therapist or
counselor who’s early on in their ACT journey.”
—Russ Harris, author of The Happiness Trap
“The authors are right: I have always said that the best way to begin actually doing
ACT (after experiential contact with it and exposure to its principles) is to follow
a step-by-step manual with several cases. That ensures you will practice all aspects
of the approach and it distills the learning process down to smaller bits that are
easier to handle. There are other beginning ACT manuals out there but this may
now be my favorite. Thorough and yet simple, this well-written and wise volume
gently pushes you forward to learn ACT, one step at a time. Highly recommended.”
—Steven C. Hayes, Foundation Professor of Psychology,
University of Nevada, Reno, Originator and co-developer
of Acceptance and Commitment Therapy
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iii
ACT in Steps
A Transdiagnostic Manual for Learning
Acceptance and Commitment Therapy
MICHAEL P. TWOHIG, MICHAEL E. LEVIN,
AND CLARISSA W. ONG
1
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1
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America.
© Oxford University Press 2021
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by license, or under terms agreed with the appropriate reproduction
rights organization. Inquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.
You must not circulate this work in any other form
and you must impose this same condition on any acquirer.
Library of Congress Cataloging- in- Publication Data
Names: Twohig, Michael P., author. | Levin, Michael E., author. | Ong, Clarissa W., author.
Title: ACT in steps : a transdiagnostic manual for learning acceptance and
commitment therapy / Michael P. Twohig, Michael E. Levin, Clarissa W. Ong.
Other titles: Acceptance and commitment therapy in steps
Description: New York : Oxford University Press, [2021] |
Includes bibliographical references and index.
Identifiers: LCCN 2020010447 (print) | LCCN 2020010448 (ebook) |
ISBN 9780190629922 (paperback) | ISBN 9780190668990 (epub) |
ISBN 9780190629946
Subjects: LCSH: Acceptance and commitment therapy. | Psychotherapy.
Classification: LCC RC489.A32 T96 2021 (print) | LCC RC489.A32 (ebook) |
DDC 616.89/ 1425— dc23
LC record available at https:// lccn.loc.gov/ 2020010447
LC ebook record available at https:// lccn.loc.gov/ 2020010448
9 8 7 6 5 4 3 2 1
Printed by Marquis, Canada
v
CONTENTS
Prologue vii
1. What Is Acceptance and Commitment Therapy (ACT)? 1
2. Assessment 19
3. General Guide to the ACT Therapeutic Context 33
4. Session 1: ACT Orientation and Creative Hopelessness 47
Session 1 Homework 59
5. Session 2: Control as the Problem 61
6. Sessions 3 and 4: Acceptance Supported by Defusion 77
7. Sessions 5 and 6: Acceptance, Defusion, Mindfulness, and Values 93
8. Sessions 7 and 8: Acceptance, Defusion, Mindfulness, and
Self- as- Context 109
9. Session 9: Values 119
10. Session 10: Values and Behavioral Commitments 133
11. Session 11: Maintaining Growth 141
Appendix A. General ACT Principles 149
Appendix B. Session- by- Session ACT Cheat Sheet 151
Appendix C. Behavioral Commitment Worksheet 155
Appendix D. List of Mindfulness Apps 157
Appendix E. NOTE Handout 159
Appendix F. Valued Living Questionnaire (VLQ) 161
Appendix G. Bull’s- Eye Values Survey (BEVS) 165
Appendix H. Self- Guided ACT Resources 169
About the Authors 173
Index 175
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vii
PROLOGUE
The idea for this book came to me at the end of a workshop I (M.P.T.) was
delivering in Augusta, Georgia, to a group of Army psychologists and other
mental health professionals who work at the Veterans Administration. This was
a training event where someone higher up invited me and the audience was in-
formed that they were required to attend the training. These are always interesting
situations because the curiosity in the topic varies among the audience members.
Some are really pleased that training on ACT is being offered, whereas others have
never heard of ACT before or are not interested in it. In general, these audience
members in Augusta were skeptically open; they were hopeful that the training
would be useful to them and the people they serve, but they were not going to
simply buy into whatever I was saying.
The two days went quite well. We talked about working with posttraumatic
stress disorder (PTSD), wounded warriors, chronic pain, depression, substance
abuse, and many other topics. I taught the audience about philosophy of science,
the theory of ACT, its basic and applied research, and when to use ACT and when
not to. Most of our time was spent on how to implement ACT. As anyone who has
attended a training— even a multi- day one— knows, you are not going to be good
at that therapy (or whatever the training is on) after one event. I knew this from
my own postgraduate training where I experienced the same thing, but something
one of the audience members said really stuck with me. I remember this postdoc-
toral intern vividly. I still know where he was sitting, what he looked like, and the
type of clients with whom he worked. His words stuck with me because it was in
that moment I knew there was a gap in our ACT training. I had just completed a
two- day training on ACT. We did lots of role- plays. I demonstrated everything. At
the end of all this he asked me, “How do I go and do this with my clients?”
I felt disheartened. I worked hard for two days to teach these professionals how
to do ACT. They spent money and time on the workshop, yet the intern did not
know where to start, much less how to conduct multiple sessions of ACT. The
attendees knew many important things about ACT. They could identify the six
important treatment processes in clients. They even knew ways to build the target
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viii Prologue
processes. Still, the intern did not know what to say in session one and how to
logically build on that.
Even as the trainer of that workshop and many others, I have to agree with him.
I have never been able to walk out of a training and do the thing that was taught.
I usually learned that the topic was interesting, I liked it, and I was interested in it,
but not how to go and do it. This training gap is exacerbated by the fact that the
instructor leaves after the training. This intern was left on his own. He stayed in
Georgia while I flew back to Utah. I felt frustrated because I get a question like this
at almost every training I give. Maybe other trainers are more talented than me
and their attendees can implement the therapy after their workshops. However, if
this is not the case, then there are many people who have learned enough about
ACT to have an interest in it but lack the resources to actually implement it. I tell
attendees the same thing:
ACT is a therapeutic model that orients to a set of key processes to work
on with clients, rather than a protocol with prescribed techniques, so there
is no manual. There are six processes of change that you should assess for
in your client. Then, you assess the degree to which those processes are af-
fecting the treatment target. You should use any variety of ACT techniques
to influence the pertinent processes of change. As those processes shift in
the desired direction, you should see improvements in the treatment target.
There are books that describe ACT for different clinical presentations which
should offer some guidance. The issue is: with the exception of a few books,
ACT is explained by each process, rather than by session. This is great in
every way except for learning how to do it. There are a couple self- help books
that explain it session-b y- session. Maybe reading those will help you un-
derstand what ACT looks like in real life. There are also videos, but they are
really expensive. You can find a few online. Also, join ACBS (Association for
Contextual Behavioral Science) because there is lots of good material there
and their membership fee is quite low.
This is an odd thing to say to someone after they spend two days getting
trained! I am basically saying, “If you want to start doing ACT, you are going to
need to start studying.” Everything is available, but you are going to need to make
sense of it. Mike Levin and I went to graduate school at the University of Nevada,
under the supervision of Steven Hayes, who is primarily associated with the de-
velopment of ACT. Guess how we learned to do ACT? We followed a manual!
I followed a manual on ACT for about two years before I slowly started to un-
derstand what was going on in ACT. My actions were shaped by the client and
my supervisors. I got better at seeing the six processes of change and thinking
about what needed to be targeted next. I started saying things that were not in the
manual but from books, videos, or what I learned from my colleagues. The flow
of sessions got smoother. I started doing ACT. Now, I teach a graduate course on
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Prologue ix
ACT and supervise a practicum on ACT. Newer therapists follow manuals or self-
help books as they get going.
All this is a long-w inded way of saying: We think it is just fine—e ven wise—
to start doing ACT by following a manual. Somehow your interest was piqued.
Maybe you attended a training on ACT, you read an article or two, or this book
was assigned to you in a graduate course. Nonetheless, you are going to start using
this approach with your clients. We hope that this book will be a useful guide
through your first five or so clients. You will learn how ACT works, when the key
processes of change are present, how to move those processes, and when the ses-
sion feels meaningful, among other things. You will start to see what you do and
do not know, and you can find ways to improve those skills. This book is your
stabilizer— your training wheels—t o get you started. This book is hopefully more
useful than a manual because it is written for a novice learning how to do ACT.
We hope it is also more useful than following a self-h elp book because it is written
for a therapist, not a client. We hope this book is what you need for the beginning
before you move on to more advanced material. Good luck!
