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 A cceptance &
C ommitment
T herapy
for the Treatment of Post-Traumatic
Stress Disorder &
Trauma-Related Problems

A Practitioner’s Guide to Using

Mindfulness & Acceptance Strategies

ROBYN D. WALSER, PhD

DARRAH WESTRUP, PhD

New Harbinger Publications, Inc.

 Publisher’s Note
This publication is designed to provide accurate and authoritative information in regard to the subject matter
covered. It is sold with the understanding that the publisher is not engaged in rendering psychological, financial,
legal, or other professional services. If expert assistance or counseling is needed, the services of a competent professional
should be sought.

Distributed in Canada by Raincoast Books

Copyright © 2007 by Robyn D. Walser and Darrah Westrup

New Harbinger Publications, Inc.
5674 Shattuck Avenue
Oakland, CA 94609
www.newharbinger.com

All Rights Reserved

Printed in the United States of America

Acquired by Catharine Sutker; Cover design by Amy Shoup; Illustrations by Susan Pickett;
Edited by Carole Honeychurch; Text design by Tracy Carlson

ISBN-13: 978-1-60882-333-8

The Library of Congress has cataloged the hard cover edition as:
Walser, Robyn D.
Acceptance and commitment therapy for the treatment of post-traumatic stress disorder and trauma-related
problems : a practitioner’s guide to using mindfulness and acceptance strategies / Robyn D. Walser and
Darrah Westrup.
p. ; cm.
ISBN-13: 978-1-57224-472-6 (hardcover)
ISBN-10: 1-57224-472-0 (hardcover)
1. Post-traumatic stress disorder--Treatment. 2. Acceptance and commitment therapy. 3. Trauma--Treatment.
I. Westrup, Darrah. II. Title.
[DNLM: 1. Stress Disorders, Post-Traumatic--therapy. 2. Cognitive Therapy--methods. 3. Stress Disorders,
Traumatic, Acute--therapy. WM 170 W222a 2007]
RC552.P67W374 2007
616.85’2106--dc22
2006102707

13  12  11

10 9 8 7 6 5 4 3 2
 Contents

  Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

  Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

  Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1  Acceptance, Mindfulness, and Trauma: The Problem of Experiential

Avoidance and the Verbal Nature of Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . 7

2 Mindfulness and Acceptance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

3 Preparing to Begin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

4  Creative Hopelessness: Finding the Place Where Something

New Can Happen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

5  Control as the Problem: Experiential Avoidance and

Unworkable Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

6 Willingness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

7 Self-as-Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

8 Valued Living. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

9 Committed Action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

10 Therapist and Treatment Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195

11 Clinical Issues and Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

   Conclusion: Opening to Vitality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

  References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

  Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
iv   
 Acknowledgments

We would like to thank all those who have provided support in putting this book
together, including friends and family. Most importantly, we each would like to thank
our husbands, Mark Castoreno and Andrew Aitken. They have supported and tol-
erated many hours devoted to writing at the temporary expense of hours devoted
to being together. We would like to acknowledge and thank Steven Hayes, whose
incredible mind and talent have provided us with this compassionate approach to
addressing human suffering. Finally, we would also like to thank our clients, who
have struggled through this therapy, changed their lives, and provided hope for others
who seek treatment for PTSD.
We would like to offer a special thanks to Susan Pickett (Robyn’s wonderful
mom) for illustrating this book and for taking the time to put her artistic talents to
work. Thanks, Mom!
 Foreword

ACT and the Disorderly Process of Trauma

There is a special relationship between Acceptance and Commitment Therapy (ACT)
and the field of trauma. There are a number of reasons for it, but I think one of
these is deep and philosophical. It has to do with the nature of trauma and a parallel
message inside ACT itself.
Behavior therapy has always had a kind of “can do” attitude, linked to an orderly
agenda. It was built on the idea that carefully defined and empirically tested interven-
tions, linked to basic behavioral principles, would allow human beings to get their
activities more fully in order. When cognitive concepts were brought into the center
of behavior therapy in the 1970s, that attitude did not change. Gone was the link
to basic behavioral principles, but there was confidence that carefully defined and
empirically tested interventions would allow human beings to get their minds more
fully in order.
Inside the “can do” attitude of both of these first two generations of behavioral
and cognitive therapy was a hidden problem, however. The cognitive and behavioral
tradition implicitly adopted cultural beliefs about the importance of getting actions
and attitudes “in order.” A great deal of effort was put into creating emotional and
cognitive lives that were, well, tidy. We would get rid of bad feelings and create good
ones. We would get rid of bad thoughts and replace them with healthy ones. Neat.
We are revisiting that issue now in the third generation of behavioral and cogni-
tive therapy. Concepts like acceptance and mindfulness are not focused on the content
of thoughts and feelings, but on our relationship to them. This is not a superficial
change. It means we are fundamentally changing our view of whether order as we
formerly understood it is important.
 That very change is a somewhat confusing process. Challenging assumptions
always is. Acceptance and mindfulness thus not only question the importance of
orderliness in terms of form—they create disequilibrium in the field itself. Challenging
order creates disorder. That very effect can be exciting, but it is not easy. In this era
of development, everything is back on the table. And at a deep level, what is on the
table is the whole issue of purpose. Instead of lives that are orderly, maybe it is better
to seek lives that are open, flexible, and connected. Instead of feelings that are positive
and controlled, maybe it is better to seek feelings that are deep, known, and accepted.
Instead of thoughts that are proper, balanced, and rational, perhaps it is better to seek
a relationship with our thoughts that is mindful, defused, and undefended.
The deep philosophical relation of all of this to trauma is based on an interesting
parallel process. So far as I can recall, I’ve never heard anyone question why we use
the word “disorder” to speak of psychological difficulties. I suspect it is because of this
secret embrace of a culturally established idea that a good life is an orderly process,
and that other processes are, well, part of a “disorder.”
It does not seem to be true. Human lives generally are not tidy. We are filled
moment to moment with feelings, memories, sensations, urges, and thoughts—and
they are often messy, painful, and conflicting. Life itself can produce unpredictable
challenges.
No one knows that better than trauma survivors. The very nature of trauma raises
the issue of order forcefully, unavoidably, and painfully.
You do not have to work in the area of trauma very long before you see how
­virtually random events can create disorder out of order. The woman in the wrong
place at the wrong time is brutally raped. The driver who happens to be in that par-
ticular car at that particular instant is terribly burned. The young soldier sees horrors
that others can only imagine, for no reason other than a series of the minute choice
points and random factors that lead to being exactly there exactly then. And when
these things happen, things change. Sometimes, everything changes. Things are mixed
up—they don’t fit.
This is part of what is hard about trauma, but it is also what is potentially empow-
ering about such painful experiences. Just as learning of a life-threatening illness often
causes people to come to grips with their own mortality and focus on what is truly
important, so too trauma survivors have an opportunity presented to them by being
required to face facts that in normal life many will turn away from and simply refuse
to see. If we can find a way forward, carrying these facts, we can reach another level
of peace and power that the illusion of control can never produce.
We live inside assumptions of safety, coherence, control, progress, and fairness.
We build stories about the way life is supposed to be and who we are. We then
live inside these stories, fearfully and uselessly avoiding the massive amount of data
that constantly questions them. Unexpected and horrific pain is for someone else, not
us. Accidents are somehow the fault of those experiencing them. And after all, good

viii   
things will happen to those who follow the rules. These illusions suggest that we are
in charge of almost everything. Most of all they suggest that the world is orderly. This
set of assumptions is safe, comfortable, and deluded.
Trauma experiences show how many of our day-to-day assumptions are based on
an insanely thin veneer of “sanity.” They show how much of our story is illusion and
pretense. Bad things do happen to good people. It does not have to be for a reason.
Sometimes children do not grow up. Sometimes careers are cut short. Sometimes
innocence is lost. And often these things are beyond our control.
Trauma survivors know how deeply this reaches. We cannot assume that the
building will not fall down, or that the car will not swerve, or that the stranger will
not attack. Even your own face cannot be relied on to be there tomorrow. Life is not
orderly.
This is the sense in which I mean that there is a special relationship between
ACT and the field of trauma. ACT asks whether it is possible to let go of conscious,
deliberate, purposeful control when that no longer works. Instead it walks through
the process needed to come into the present and still to care, even when we have
­abandoned the security blanket of feel-goodism and the illusion of omnipotence.
This book, by master ACT therapists and trainers, carefully and systematically
prepares clinicians to explore this territory. As befits its deep message, the book is not
so much a formula as it is a space within which to examine deeper questions. Is it
possible and healthy to support trauma survivors to be themselves, to be present, and
to care, without trying first to create formal order out of the mix of thoughts and feel-
ings that traumatic experiences leave behind? ACT therapists and researchers think
the answer is yes. We are just learning how to do that, and vastly more research and
clinical development are needed. But this book provides the first comprehensive start-
ing point for this new journey. We are eager to take it, sensing that along this path
lies a way to turn even horror to profound good.
ACT, and the third generation of behavioral and cognitive therapies generally,
can be confusing and disorienting because they challenge fundamental assumptions.
For researchers and clinicians interested in trauma, perhaps that is as it should be. It
puts us into the very shoes of the clients we serve—people whose unbidden experi-
ences have done the same thing. Rather than grab even more tightly at new forms of
control, ACT asks clinicians and clients alike to put down the needless defenses, show
up, and begin to live in a more open, compassionate, and values-based way, knowing
full well that painful events can penetrate human lives at any moment.
—Steven C. Hayes
University of Nevada

Foreword   ix
 Introduction

The single most remarkable fact of human existence is how hard it

is for human beings to be happy.

— Steven C. Hayes

Getting Started
This book is a practical clinical guide on the use of acceptance and commitment
therapy (“ACT,” said as one word) in the treatment of post-traumatic stress disorder
(PTSD) and other trauma-related problems. Because mindfulness is a central skill in
ACT, we also include mindfulness as an integrated topic. This book is designed to
show how ACT and mindfulness apply to these particular difficulties and how they
can be used in different settings and modalities (that is, in both group and individual
therapy) and with different types of traumatic experiences. It is our hope that the
therapists who choose to read and work with this book will find it to be comprehen-
sible and user-friendly, providing both a solid understanding of ACT theory as well as
the practical resources needed to apply ACT and mindfulness with this population.
We are writing this book based on the clinical and research experience gained
during our long-standing use of ACT and mindfulness with clients suffering from the
effects of trauma. We each have more than a decade of experience in treating PTSD
and have worked together with ACT for more than six years, using this treatment
approach in our private practices, outpatient clinics, and inpatient settings for clients
with trauma-related problems and PTSD. We have provided ACT to both men and
women in individual and group settings, and we have had experience with many
types of trauma, ranging from motor vehicle accidents and natural disasters to sexual
trauma and war-zone-related trauma. It is our experiences in using ACT and mind-
fulness with this population that have inspired this book and the examples provided
therein. It should be noted that in the interests of confidentiality we have masked
the identities of individual clients or provided examples that are amalgams of various
clients and therapy interactions. We would like to add that the text Acceptance and
Commitment Therapy: An Experiential Approach to Behavior Change (Hayes, Strosahl,
& Wilson, 1999), which provides a more detailed theoretical explanation and a full
account of this approach, has been an important resource.
In addition to the experience noted above, we have conducted workshops in the
use of ACT and have regularly presented ACT concepts and empirical findings at the
International Society of Traumatic Stress Studies (Walser, Westrup, Rogers, Gregg, &
Loew, 2003; Walser, Westrup, Gregg, Loew, & Rogers, 2004; Walser, Gregg, Westrup,
& Loew, 2005) as well as the Association for the Behavioral and Cognitive Therapies
(Walser & Hayes, 1998). We also train students to use this approach with individuals
who have been diagnosed with PTSD. In fact, one of our more rewarding experiences
has been our ongoing supervision group, wherein we not only provide ACT training
but also actively work with ourselves and our students to live according to our own
values, thus implementing ACT in our own lives.
We are also both scientists and have contributed our own findings regarding the
effectiveness of ACT as a treatment for PTSD. We are very interested in empirical
work in the area of understanding human suffering and its treatments. Research on
both ACT and mindfulness is booming, and there are a number of important studies
emerging that support ACT and mindfulness as effective interventions and that suggest
that the theory and concepts underlying ACT predict change processes in treatment.
The overall goal of this book, however, is not to review the scientific literature, but
to provide the nuts and bolts of the intervention. We currently conduct ACT and
mindfulness groups on a regular basis and hope to communicate these experiences in
a way that proves straightforward to you, the reader, as both therapist and person. We
want to not only provide you with a clear sense of how ACT is conducted, but also
convey the strength of compassion for human experience found in this therapy. ACT
is designed to create both psychological and behavioral flexibility in clients through
processes that are applied with warmth and compassion for the client’s struggle and
for the difficulties that traumatic experience can bring. We are guided by our value of
bringing kindness to our therapy and our belief that the client is 100 percent accept-
able as they are in this moment. Yet we also hold firm to the notion that clients can
always choose to take action that is directly in line with their personal values.

2  
 We do want to refer readers to a Web site and several publications that provide
empirical findings and reviews of the ACT and mindfulness literature. First, please
see the Web site of the Association for Contexual Behavioral Science for references to
both theoretical and empirical papers plus other ACT-relevant information: www.con-
textualpsychology.org. We also recommend that you read other key works about ACT,
including Acceptance and Commitment Therapy: An Experiential Approach to Behavior
Change by Steven Hayes, Kirk Strosahl, and Kelly Wilson (1999), Get Out of Your
Mind and Into Your Life by Steven Hayes and Spencer Smith (2005), A Practical Guide
to Acceptance and Commitment Therapy by Steven Hayes and Kirk Strosahl (2004), and
Acceptance and Commitment Therapy for Anxiety Disorders: A Practitioner’s Treatment
Guide to Using Mindfulness, Acceptance, and Values-Based Behavior Change Strategies
by Georg Eifert and John Forsyth (2005). For a literature review of mindfulness,
please read Ruth Baer’s journal article entitled “Mindfulness Training as a Clinical
Intervention: A Conceptual and Empirical Review” (2003). We also suggest that you
read Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition, edited
by Steven Hayes, Victoria Follette, and Marsha Linehan (2004), Full Catastrophe
Living, by John Kabat-Zinn (1994), and Acceptance and Mindfulness-Based Approaches
to Anxiety, edited by Susan M. Orsillo and Lizabeth Roemer (2005).
Finally, we have each been profoundly moved by the transformations we have wit-
nessed in doing this powerful intervention. We have worked with many clients who,
having previously deemed their lives destroyed by their trauma, are aided by ACT to
embrace living in ways that are meaningful and value driven.

How to Use This Book

This book is intended as a practical guide for clinicians who wish to use ACT with
clients who are struggling with PTSD and trauma-related issues. The central focus
is on the actual course of therapy as applied to this particular population, and, as
mentioned, the material draws extensively from the authors’ direct experience in using
ACT with both men and women with PTSD. As you read the separate chapters, we
recommend that you explore how the principles and techniques of ACT might be
employed in your own life, as well as considering how you might use the approach
with your clients. You may want to complete the homework assignments provided at
the end of the chapters specific to the intervention, as they provide a hands-on oppor-
tunity to develop your own acceptance and willingness as it applies to your personal
internal experiences. As it applies to your clients, each of the therapy chapters (4, 5,
6, 7, 8, and 9) contains two homework assignments. We provide two (in most cases),
as most of the therapy topics will need more than one session to be completed. You
can use the homework assignments in the way that seems most appropriate for the
client and for the amount of time you spend on each topic. If the topic takes more

Introduction   3
than two sessions, feel free to draw on other homework assignments in the book that
went unused or to develop your own—perhaps those that are specific to the client’s
needs. Finally, as you continue to learn how to implement ACT, you can also try out
metaphors or experiential exercises with clients as a way to familiarize yourself with
the therapy. We strongly recommend use of ACT and mindfulness in your own life if
you wish to be effective at providing this intervention to your clients.

Structure of This Book

The first four chapters of this book serve as an overview and starting point to ACT.
Following this introduction, chapter 1 introduces the concept of experiential avoid-
ance and key principles of ACT. This serves as a foundation from which to approach
the remaining chapters and is central to understanding the therapy.
Because the concept of mindfulness is a key construct in ACT and one that both
clinicians and clients often find challenging, we follow the theory chapter by dis-
cussing mindfulness and its importance to the ACT approach in chapter 2. Just as
the regular practice to become more mindful must be integrated into daily life, the
concept of mindfulness is woven throughout the book as a necessary element that
is continually built upon. In chapter 2, we will explore different mindfulness tech-
niques, and we recommend that you practice both personally and with your clients.
Additionally, as you read the therapy session chapters (4, 5, 6, 7, 8, and 9), you will
see that each session is opened with a mindfulness exercise. Two are provided for each
chapter. As noted above, we have included two, as it often takes more than one session
to cover any particular core topic of ACT. You can use the second mindfulness exer-
cise in an additional session. Should you find that you spend more than two therapy
sessions on any particular topic, feel free to repeat mindfulness exercises, to draw from
other mindfulness exercises in the book, or to use your own mindfulness exercises.
We have tried to match the mindfulness exercises with level of experience (mindful
breathing at the beginning) or with the core topic that is being presented. We rec-
ommend use of the mindfulness exercises that accompany a particular chapter. That
said, there is no hard-and-fast rule about which mindfulness exercises are done when.
You can feel free to exercise some flexibility around their implementation. Finally, we
recommend that you ask your clients to purchase a notebook or journal, as they will
be asked to report on their mindfulness experiences, and keeping track in a journal
will help them to see their progress. Chapter 3 will explore the process of “prepar-
ing to begin.” It will address how to describe the therapy to the client, including
informed consent and general issues related to beginning the therapeutic process from
this approach.
In chapters 4 through 9, we present the major ACT components in chronologi-
cal order. That is, ACT is a “building block” therapy, wherein the client is taken

4  
on a journey that (a) systematically undermines problematic control and avoidance
strategies; (b) establishes a framework wherein clients can directly experience their
thoughts, feelings, and sensations without employing harmful change strategies; and
(c) helps clients arrive at a place where they can choose to take committed action in
accordance with their values—ACT’s main focus of change. It is recommended that
first-time readers read the text front to back in order to best appreciate this step-by-
step process. Once you become facile with the material, then it is easier to loosen the
step-by-step structure and more readily pull in pieces of the therapy from the different
core areas wherever they are needed.
Chapters 4 through 9 will explore and describe the core components of
ACT, which are introduced in the same order as they would be conducted in the
therapy: “Creative Hopelessness” (chapter 4), “Control as the Problem” (chapter 5),
“Willingness” (chapter 6), “Self-as-Context” (chapter 7), “Valued Living” (chapter 8),
and “Committed Action” (chapter 9). Each chapter details how to introduce and work
with each concept as it pertains to the client with PTSD, and case examples are used
to highlight particular challenges associated with each topic. The sections also include
exercises and homework that will assist the clinician to move the client through each
core component.
ACT is a very hands-on therapy, and the therapist’s own stance with regard to
experiential avoidance and acceptance can serve to both significantly enhance and
seriously impede the work. Chapter 10, “Therapist and Treatment Considerations,”
addresses issues of therapist compassion, authenticity, and self-care as viewed from
an ACT perspective and addresses training considerations. Chapter 11 further exam-
ines specific treatment considerations such as the application of ACT in various
PTSD populations and comorbid conditions that are often present when working
with traumatized individuals. This chapter also discusses assessment as it applies to
ACT—­specifically, ways in which therapeutic movement in such areas as mindfulness,
trauma, and acceptance can be evaluated and monitored. Finally, in the conclusion
we briefly present data and offer our final thoughts about working with individuals
recovering from trauma.

Introduction   5