“I love the matrix. Sometimes you need a way of thinking about ACT that is so focused on what is critical and so simple that you cannot forget it. That’s the matrix. The number of situations that call for it is stunning: as a tool for difficult clients; when you feel lost in therapy; for an elevator speech with a business person; to do a thirty-minute talk with a lay group; to guide a chat with a school principal; and on and on. This is the first book on the matrix and how to use it. Let me simplify it for you: Get it. Read it. Use it.” —Steven C. Hayes, PhD, cofounder of ACT and professor of psychology at the University of Nevada “This book is a must-have for anyone interested in practicing or teaching ACT.” —JoAnne Dahl, PhD, professor of psychology at Uppsala University, Sweden, and coauthor of ACT and RFT in Relationships “The matrix method of delivering ACT has experienced a rapid increase in popularity in the last few years. The ACT Matrix provides a simple, mindful framework for delivering ACT in a wide number of contexts, including areas involving emotional disorders, eating disorders, addiction, pain, post-traumatic stress disorder (PTSD), and pro-social behavior. It can be used in the clinic, in schools, in organizations, or any setting [where someone] would benefit from increased psychological flexibility and resilience. If you would like a quick, accessible way to learn and start practicing ACT, this book is for you.” —Joseph Ciarrochi, PhD, author of the best-selling teen book, Get Out of Your Mind and Into Your Life for Teens “The matrix is transparent and user-friendly for both mental health and medical providers working in brief treatment settings. As a matrix practitioner, you will help many people, including those with addictions, chronic pain, and relationship problems. Add The ACT Matrix to your bookshelf now and benefit from Polk and Schoendorff’s numerous examples of how to use this highly accessible tool.” —Patricia J. Robinson, PhD, author of Real Behavior Change in Primary Care and Brief Interventions for Radical Change “In The ACT Matrix, editors Kevin Polk and Benjamin Schoendorff simplify the entire ACT model into two basic distinctions. The first two chapters of the book, written by the editors and collaborators, summarize the matrix diagram by discriminating between sensory and mental experiencing and between moving toward versus away from your values. These are well-written and entertaining. I was unfamiliar with the matrix, and after reading these introductory paragraphs, I had a good feel for what the work would look and feel like with a client in the therapy room. “The remaining chapters of the book apply to specific settings, presenting problems and populations. I believe that you could skip to whatever work you most commonly do, or read straight through—either would be useful! These chapters are written by practitioners who are experts in each of the areas, and the subtle details of how the matrix can be used differently with each issue really shine through. I believe this will be a great addition to many office bookshelves, and I would say to pick up a copy right away!” —Amy R. Murrell, PhD, associate professor at the University of North Texas AC T m Atr i x The A New Approach to Building Psychological Flexibility Across Settings & Populations Edited by KEviN L. PoLK, PhD BENjAmiN SchoENDorFF, mA, mSc Context Press An Imprint of 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. “The Bull’s Eye” and “Join the DOTS” from ACT MADE SIMPLE by Russ Harris, copyright © 2009 Russ Harris. Used by permission of New Harbinger Publications, Inc. Distributed in Canada by Raincoast Books Copyright © 2014 by Kevin L. Polk and Benjamin Schoendorff New Harbinger Publications, Inc. 5674 Shattuck Avenue Oakland, CA 94609 www.newharbinger.com All Rights Reserved Acquired by Tesilya Hanauer; Cover design by Sara Christian; Edited by Jasmine Star; Text design by Tracy Marie Carlson; Indexed by James Minkin Library of Congress Cataloging-in-Publication Data The ACT matrix : a new approach to building psychological flexibility across settings and populations / edited by Kevin L. Polk, PhD, and Benjamin Schoendorf, MSc, MPs. pages cm Includes bibliographical references and index. ISBN 978-1-60882-923-1 (pbk. : alk. paper) -- ISBN 978-1-60882-924-8 (pdf e-book) -- ISBN 978-1-60882-925-5 (epub) 1. Acceptance and commitment therapy. 2. Mental illness--Psychological aspects. 3. Adaptability (Psychology) I. Polk, Kevin L., 1955- II. Schoendorf, Benjamin. III. Title: Acceptance and commitment therapy matrix. RC489.A32A28 2014 616.89’1425--dc23 2013050528 wondrous.The love of my life. Mary Alyce Burkhart. PhD. —Kevin Polk To all the people who have made it their life’s mission to ferry others through the dark straits of their suffering over into a life worth living. and collaboration lift me each and every day. and my fervent hope is that you’ll find within these pages a seaworthy vessel in which to safely steer through the waters of this scary. Her love. support. —Benjamin Schoendorff . Ours is a sacred calling. and ultimately beautiful life. . Me. and Kevin Polk PART 2 Populations and Settings 3 ACT for the Masses: Using the Matrix with the General Public�����������������������������������������������������������41 Aisling Curtin 4 You.CONT ENTS Introduction: What the Matrix Is All About ���������������������� 1 Kevin Polk PART 1 Understanding the Matrix 1 The Psychological Flexibility Warm-Up �������������������� 7 Kevin Polk 2 Under the Hood: Basic Processes Underlying the Matrix���������������������������������������������������������������� 15 Benjamin Schoendorff. and the Matrix: A Guide to Relationship-Oriented ACT�������������������������������������57 Benjamin Schoendorff and Marie-France Bolduc 5 Rolling Out the Matrix. Mark Webster. Rolling Back Addiction���� 77 Mark Webster 6 The Pain Matrix������������������������������������������������������ 93 Amanda Adcock Vander Lugt 7 ACT in Digestible Bites: The Matrix and Eating Disorders �����������������������������������������������������109 Florian Saffer . The ACT Matrix 8 Out of the Hole: The Matrix with Chronic and Severe Symptoms���������������������������������������������129 Rob Purssey 9 Something You Can Never Forget: The Matrix and PTSD���������������������������������������������������������������147 Kevin Polk and Mary Alyce Burkhart 10 Spot the Matrix: Psychological Flexibility in Private Psychiatric Practice�������������������������������������163 Jean-Michel Vincent 11 Casing the Matrix: A Tool for Case Conceptualization���������������������������������������������������181 Benjamin Schoendorff PART 3 The Matrix Outside the Box 12 The Matrix Goes to School: Promoting Psychological Flexibility in Education�������������������� 207 Phil Tenaglia 13 In Business: The Matrix for Team Building and Professional Stress��������������������������������������������221 Annick Seys 14 The Matrix. and Improving Work- roup Functioning with Ostrom’s Eight Design G Principles�����������������������������������������������������������������235 Kevin Polk Conclusion: Going Viral ���������������������������������������������������251 Kevin Polk and Benjamin Schoendorff Index���������������������������������������������������������������������������������257 vi . Evolution. (That is. it can really only be written after the class has happened.” but it was entirely typical for my little training group. a couple of press pots of dangerously strong coffee brewing in the kitchen. a six-month-old baby. we drop everything and chase it. I have run an acceptance and commitment therapy seminar every other spring. and nursing grad-student mom. We pursue interesting topics. I am not quite sure what Kevin thought when he arrived at my house. interested and ready to learn. I use what one might generously describe as a fluid syllabus. The timing was right. Kevin Polk.) Ole Miss has allowed me considerable latitude to use these seminars as a place for intellectual and experiential play. He found a living room full of students. who would be my student’s supervisor. They are typically composed of seven or eight graduate students. What followed was a description of ACT in groups that was unlike anything I’d ever . The seminars are odd. so it was a natural fit to have Kevin come and talk to my grad students about the ways he was using ACT in groups of veterans suffering with post-traumatic stress disorder. I host them at my home. And. if we see something new and interesting. I am sure it seemed odd to someone who thought he was visiting a “class. was traveling to Mississippi and asked about stopping in Oxford. I had just placed one of my graduate students at the Togus Veterans Administration Medical Center. In the spring of 2007.Foreword Since I arrived at the University of Mississippi in 2000. I briefly introduced Kevin and gave him the floor. We were all there. prodded. continued to innovate and refine. I told him that he had to come to the upcoming Association for Contextual Behavioral Science (ACBS) World Conference in Houston. begged. As fate would have it. and memories were all things to be sorted and noticed on the way to a richer and more meaningful life. and.The ACT Matrix seen. It was active. I am not easily dissuaded. With the right audience. the assembly of the conference program was far less formal than it is now. One of them called it “ACT Gone Wild. It was simple. viii . Loud and clear! As I recall. and pointed out how many people could be helped. it was intently focused on growing rich and meaningful lives. ACT Gone Wild became the “iView” and then. so he ended up with a big room for his international unveiling of ACT Gone Wild. a couple of months before the conference. Jerold Hambright. useful tools that could help them understand and assist clients. told him how important it could be. I poked. and told Emily Rodriguez. eventually. Hard thoughts. Kevin and his partner in the development of this work.” and the name stuck. but not a lot. I knew that this work would spur wonderful innovations and applications.” What was created was quickly given away. I got a tentative yes that day and a definite yes soon after. and it was brilliant. “the matrix. The result has been an explosion of work with the matrix all over the planet. People loved it. PTSD treatment can be pretty grim. From my living room to the world conference in a couple hours’ time was quite a leap! However. with paper submissions spread all across the floor. I asked Kevin what he was doing in July. while sitting in the car with Kevin. the executive director. “We need you!” was my message. Back in those days. The students loved it. I think it had become a bit more organized by 2007. that we just had to get this guy on the program. but there was nothing grim about this treatment. to my delight. Kevin hesitated. I called the ACBS office. some other things were canceled during Kevin’s first ACBS conference presentation. I recall putting some early programs together in a hotel room. along with other colleagues. Riding with Kevin back to his hotel. I knew that I wanted to see these ideas loosed on the ACT community of scientists and practitioners. it was vital. emotions. Clinicians needed simple. In the intervening years. When he gave the slightest indication that July might be open. This work had to be moved beyond the VA Medical Center to the broader treatment development community. Wilson. I am a researcher and treatment developer. within minutes. Kevin Polk and Benji Schoendorff have assembled a wonderful resource. and all of my supervisees use the matrix. —Kelly G. I have always found it to be a cumbersome tool to use while doing therapy. Clients and clinicians can. You need this book. and I recommend the matrix for use in every protocol. in supervision. from Oxford. and in case presentations. and I use the matrix with my own clients. Mississippi. PhD Professor of Psychology University of Mississippi ix . The matrix spans the gap between clinical practice and the more complex psychological flexibility model. Namaste y’all. and I introduce the matrix at every workshop. I cannot recommend this book highly enough. and I use the matrix to look at the ways my own life is working. I am a clinical supervisor.Foreword I currently use the matrix in treatment. I am a clinician. I am a trainer. If you are any of the above. While the six-process psychological flexibility model has proven an incredibly useful tool in treatment development and research. understand the thrust of case conceptualization and treatment. I am a person. . I NT RODUC T ION What the Matrix Is All About Kevin Polk The matrix is an interactive diagram for increasing psychological flexibility in almost any context at any time. The matrix is for sharing. you have only one agenda: increasing psychological flexibility and valued living. People interact with the diagram and experience having thoughts. feelings. and it’s best learned with the notion that you will teach others how to share it with others. .” The name stuck. The matrix works best if it’s paid forward. and publications on the philosophy and theory behind ACT were even more sparse.” but later a friend suggested we call it the matrix because “The matrix has Keanu Reeves sexy–attached to it. will discover that while using the matrix to influence others. It is a diagram of the process of acceptance and commitment therapy (ACT). referred to as acceptance and commitment training when working with the general public. You. The matrix is a result of over ten thousand hours of work beginning in 2004. At that time there weren’t so many ACT books. and urges that they would rather not have while choosing to take action toward who or what is important. How the Matrix Came to Be The diagram was first called “the grid. the reader. I could see that ACT boiled down to two sorting tasks: noticing the difference between sensory and mental experiencing. and “Away” to the left. Finally. with “Five-Senses Experiencing” at the top. walked over to one of my whiteboards. “Toward” to the right. Five-Senses Experiencing Away Noticing the differences Mental Experiencing 2 Toward . “Mental Experiencing” at the bottom. participated in well over one thousand sessions of ACT. in 2009. I stood up.The ACT Matrix So after going to one conference and reading what we could about ACT. and drew the two lines of the diagram. Noticing the differences is where the lines cross. I love to create simple diagrams. in my mind’s eye. By 2009 I had read pretty much every book and article about ACT. and noticing the difference between how it feels to move toward important stuff and how it feels to move away from unwanted mental experiencing. my colleagues Jerold Hambright and Mark Websterand I began to use the approach. and engaged in hundreds of in-depth conversations. and I worked the diagrams all the while. I was almost finished reading the latest ACT book when. Whatever approach you take in your reading. As you share the matrix with others. your psychological flexibility will increase. Word spread. Such is the nature of the psychological flexibility promoted by the matrix. perusing the topics that are most important to you. beginning with a basic matrix “warm-up” routine to get you started. Prisons were one of the next stops. You might also notice some people giggling just a bit while noticing the differences.What the Matrix Is All About How the Matrix Travels It wasn’t long before I was on the Internet showing the matrix to others. and people began to use the matrix in a variety of contexts and settings. and then in schools. Learn to introduce people to the psychological flexibility point of view by having them notice the difference between sensory experiencing and mental experiencing. you’ll quickly start to discover your own uses for the diagram. 3 . after reading chapter 1. You can always come back later to read other chapters and find new ways of using the matrix diagram. As a matter of fact. You might notice interest showing up on people’s faces as you have them notice those differences. feel free to skip around the book. if you want to use the matrix. but sadly. first in hospitals and mental health clinics. All of this travel with no formal publication to its name…until now. taking the matrix to cool new places. and then notice the difference between how it feels to move toward important stuff and how it feels to move away from unwanted mental experiencing. memorize the warm-up and show it to others. It’s probably best if you read that chapter first. and you’ll dream up new ways to use it. In this book you’ll see the matrix diagram at work in a variety of contexts. Whether you choose to learn how to do the matrix routine or not. such as fear. we couldn’t find anyone to write a chapter about using the matrix with prison populations at this time. Then the matrix found its way into boardrooms and meeting rooms. . PA RT 1 Understanding the Matrix . . It’s a warm-up for psychological flexibility and presents the skills that can help you become a great matrix practitioner.CH A P T ER 1 The Psychological Flexibility Warm-Up Kevin Polk This short chapter introduces the matrix diagram. . hear the 8 . See it. Mental Experiencing Take out a pen and notice it using your senses. hear it (by tapping or clicking).1. touch it. The basic matrix diagram. I’ll omit taste because that wouldn’t be sanitary—unless you’re really intimate with your pen.The ACT Matrix Five-Senses Experiencing Figure 1. this time using your mind. touch the pen. Five-Senses Experiencing vs. See the pen. Now remove the pen from your five senses and recall experiencing the pen. Try drawing it on a piece of paper for clients. and smell it. Simply recall moving toward someone or something that’s important to you. recall moving away from some unwanted thought or feeling inside you. Well done! Noticing Differences Throughout this book. and sometimes we’re moving away. Sometimes we’re in our heads. Now notice if there’s a difference between your five-senses experiencing of the pen and your mental experiencing of it. Toward and Away Now recall moving toward someone or something that’s important to you. You might have moved toward a loved one or some sports event. The most common one is fear. Now notice if there’s a difference between how it feels to move toward and how it feels to move away. We all move away from the feeling of fear. You’ve now completed your warm-up. and. All of us move within the matrix all of the time. taste the pen all you want. Next. Sometimes we’re more connected with the five senses. now that you’re in your mind. Knowing where you are on the diagram at any moment is sort of cool—something you’ll experience for yourself as you read on. Recall how you moved away to avoid the fear. Just notice if there’s a difference. 9 . smell the pen. and the difference between how it feels to move toward and move away. in one way or another you’ll practice noticing these two differences: the difference between your sensory and mental experiencing. Sometimes we’re moving toward.The Psychological Flexibility Warm-Up pen. toward the bottom of the diagram. The ACT Matrix Stretching Toward Psychological Flexibility The basic idea of the matrix diagram is to take the essence of psychological flexibility and grow it. you’ll find many exercises in this book devoted to clarifying and identifying the stuff that shows up inside that can sometimes be a barrier to moving toward values. feelings. we need to know the actions that can help us move toward who or what is important. In acceptance and commitment therapy lingo. this is called values and committed action. such as getting out of the way of a bus. (In matrix work. To get to the point of noticing the differences many times per day requires some training. Think of it as stretching exercises to promote psychological flexibility. we need to be aware of the actions we take too often to move away from unwanted inner experiencing. and bodily sensations that commonly show up for us. we need to have a good idea of the unwanted thoughts. 10 . we need to have a good idea of who or what is important to us. then a dozen times per day. We all do things to move away from unwanted feelings when the better move would be to take the feelings with us as we move toward who or what is important.) Again. First notice the differences a few times per day. and that’s what much of this book is about. Unwanted Inner Experience To know when we’re making an away move. and finally many times per day. Above all. bodily sensations are often regarded as mental or inner experiencing because they occur inside the skin. others are not. Who or What Is Important To know when we’re making a toward move. Further. While many away moves. are highly functional. You’ll find a great deal of values work throughout this book. urges. Getting Unstuck Getting unstuck from mental experiencing is the purpose of the matrix diagram and noticing the two differences. every once in a while you might pause and notice the difference between your five senses and mental experiencing. Sometimes we get stuck there and forget to smell the roses. and then get back to your reading. You can accelerate learning by inviting 11 . there are a couple of things to keep in mind. Noticing the Differences As you read this book. and those words take us into our mental experiencing. we notice the difference between mental and sensory experiencing and learn to have a choice.The Psychological Flexibility Warm-Up How We Get Stuck The basic idea of acceptance and commitment therapy is that people get stuck in their head (mental experiencing) and need to do some exercises to get out of their head. The primary reason for noticing the two differences is that noticing requires no language. neither is life. The title of Steve Hayes’s book Get Out of Your Mind and Into Your Life (2005) sums this process up nicely. and we’d lose our way in a hurry if we completely disconnected from it. Of course we can’t completely free ourselves from language—nor should we. It’s useful. and language is the stuff of mental experiencing. The problem is that we swim in a sea of words. then notice if you’re moving toward or away. Learning to have that choice is the essence of psychological flexibility. Instead. You’ll soon start to notice a difference. Training the Noticing When you’re teaching others to notice these differences. Whether we’re stuck moving toward or away from mental experiencing doesn’t matter. someone might be excitedly telling you about an emotionally charged event that happened last week. If you aren’t familiar with physical aikido.The ACT Matrix people to do “sorting. If you go to a restaurant. You simply say something like. You can see and hear that she’s stuck in her mental processing of the story and could probably use a break toward flexibility. or what we plan to do this weekend. And? Sometimes people get hooked into telling their story and forget to do the sorting. At these times. sort of like diagramming the story. you don’t interrupt every story this way. a quick “Yes. Yes. Those stories may be about what we had for breakfast. and?” to draw them back into sorting and noticing the differences. and?” can get the job done nicely. “Yes. emotions. Part of each story includes the five senses: what was seen. We have people do the sorting so they can practice noticing the differences. and where would you sort that last bit you were talking about?” Obviously. the person steps back and notices the differences between elements of the story. Each is a story that can be sorted into the matrix. Essentially. Verbal Aikido With “Yes. and urges. In other words. smelled.” and this sorting will help them notice the differences. we all tell stories. As people tell a story—any story—they can be invited to sort the elements of the story into the matrix. to do the sorting. there will be elements of each of the five senses in the story of the trip to the restaurant. but if it seems someone needs a little nudge toward psychological flexibility. felt. and?” we enter the world of what some call verbal aikido. The story will also include actions taken both toward and away. Every act of sorting requires noticing the differences. heard. For example. where we went on vacation last year. we use the gentle art of “Yes. it’s a martial art that involves 12 . and tasted. Each story also has mental aspects: thoughts. verbal aikido takes repeated and deliberate practice. Like physical aikido. Did the person expend much energy? Did the person fight against the hook or carry it along? What came next. Conclusion If the only thing you learn from this book is the following summary and you practice what it teaches you. the matrix practitioner often uses a simple homework assignment that involves noticing hooks. they’re inherent in the noticing. and?” is verbal aikido. Maybe a car cuts you off. The hook gets noticed. Some aikido masters say they’re showing the other person the way to peace. get free of some of the bonds of the story. maybe someone says something unkind. Noticing Hooks To move the verbal aikido practice into life. and each provides an opportunity to practice a touch of verbal aikido. even spinning it. so don’t get hooked and discouraged if you don’t always succeed in redirecting someone’s energy toward the matrix. Keep at it and you’ll soon start noticing a difference. between sensory and mental 13 . “Yes. Notice the difference experiencing. There are all kinds of emotional hooks that we each have every day. Inherent in noticing the hook and noticing what is done next is noticing the effect of the hook. a toward move or an away move? These questions are not necessarily asked directly. into the matrix. and move toward psychological flexibility. taking the energy of words and directing it. and then the next action is noticed. maybe you see a beautiful person. The energy that the person was just about to spend on being stuck in the story is now being used to sort the story. the energy is redirected.The Psychological Flexibility Warm-Up redirecting physical energy. Hooks are those moments we all have when we quickly get emotionally charged. you’ll probably become a great matrix practitioner: 1. When someone strikes out. And maybe think about this stuff being verbal aikido… 6. 14 . (2005).). 4. use “Yes. S. Notice the difference between how it feels to move toward and away. I and the other authors of this book hope you’ll join us on a journey through the many facets and applications of this deceptively simple tool for psychological flexibility we call the matrix. References Hayes. 3. invite them to sort stuck stories into the matrix. if they get stuck. and?” to get them back to sorting. Practice 1 to 5 again and again.The ACT Matrix 2. Now that you have the basic matrix moves down. Get out of your mind and into your life: The new acceptance and commitment therapy. Oakland. S. When teaching others. CA: New Harbinger. When teaching others. 5. (with Smith. and Kevin Polk The matrix is a simple way to help people to adopt a point of view that enhances psychological flexibility. Along the way. People are simply invited to notice these two . and the difference between how it feels to move toward stuff that’s important and how it feels to move away from stuff inside. We’ll briefly show you that point of view and then give you our understanding of some of what’s going on behind the scenes of the matrix. like anxiety or guilt (the horizontal line of the matrix). At its essence the matrix is a diagram that prompts the noticing of two differences: the difference between five-senses experiencing and mental experiencing (the vertical line of the matrix).CH A P T ER 2 Under the Hood: Basic Processes Underlying the Matrix Benjamin Schoendorff. including the learning of language and thinking. we’ll ease into some technical language to sketch out what we believe goes on under the hood of this deceptively simple vehicle for getting people on track to psychological flexibility and a valued life. The matrix is a tool of human liberation that rests on recent advances in the understanding of learning and cognition. Mark Webster. It’s the stuff of basic human learning. which underlie acceptance and commitment training and therapy. We look at the whole picture. maybe in your house. we look at how a person behaves in the situation the person is in at the time. So instead of basing our science on a mechanistic view. Along the way. Maybe you’re on a bus. there’s more than one way to look at things. an approach that seeks to identify what works in particular contexts. 1993). For example. Mathematic equations don’t fully do the trick when it comes to explaining behaviors—the things that make up a life. Most people can readily notice these differences. we hope to give you a better sense of what makes the matrix an effective tool in promoting psychological flexibility. humans (and living organisms in general) are not machines. we can look at life and the universe as being like a machine.The ACT Matrix differences. Why someone would have trouble noticing the differences goes to the heart of what’s going on behind the scenes of the matrix. we’ll give you some understandable highlights that might help you use the matrix more effectively. We won’t be going deep into the science because that isn’t the purpose of the chapter or this book. However. and the scientific foundation of the matrix is built on a completely different set of basic assumptions. Simply observe yourself reading these words in whatever situation you find yourself. but for some folks it’s more difficult. and a set of mathematical equations can describe that machine and how its component parts interact. Rather. The matrix is an application of functional contextualism (Hayes. What’s true isn’t how things “really” are. Basic Assumptions All science stands upon basic assumptions. You can look at the act (reading) in context (the situation you’re in). but what works in a given situation. In functional contextualism. You can do this right now. maybe in a library. rather than simply at how the constituent parts interact. Many of our Western notions of science are built on some variation of the view that the universe is like a machine. the concern isn’t about how things are in themselves or what’s true independent of what works to attain particular goals. This makes functional contextualism particularly 16 . Put simply. In this chapter we’ll lift the curtain and give you a quick run- through of what science currently has to say about human learning and cognition. rather than Newtonian physics. In the rest of this chapter. the target for treatment is long-term quality of life. this gives us the standard model of disease. A functional contextual perspective conditions a different model of health—one in which how people interact with their life situations determines the consequences of their behavior and whether their behaviors are workable in moving them toward what’s important to them. It’s an extension of Skinner’s radical behaviorism. over time. Treatment is about removing the cause to remove the symptom. Functional contextualism was developed to provide a framework for a psychology that doesn’t limit itself to identifying parts and instead takes into account how whole individuals function in their varied life contexts. This is different from the standard model to the point of perhaps seeming counterintuitive. The focus is on selection by consequences. may not work to move a person toward what’s important. Though we rarely think about them. From this perspective. diabetes is a condition that generally appears with certain behavioral patterns and that. lack of insulin is seen as the cause of the symptoms. they are important to examine. can best be treated by changing eating and exercise patterns—though at times supplementation with insulin can also help. in which an underlying cause is seen as the root of a symptom. Newtonian physics is an example of that. The matrix helps people easily operate in and navigate this seemingly counterintuitive functional contextual mode.” but what works for them in their varied life situations. the basic assumptions—or. as the philosopher of science Pepper (1961) referred to them. more often. we’ll look at the processes the matrix brings into play to help orient people toward and within a functional contextual model of mental health—one in which what’s important and how to move toward it organizes the work and becomes the criteria for 17 . in diabetes. Applied to health. and its basic assumptions are derived from Darwin’s view of evolution. so treatment implies supplementing with insulin to achieve levels sufficient to remove symptoms and restore health. For instance.Under the Hood: Basic Processes Underlying the Matrix well adapted to interventions in which what’s important isn’t what people think is “true. Therefore. root metaphors—that underlie our worldviews condition how we go about understanding things and treating people. not short-term fixes. An alternative to functional contextualism is seeking to identify the mechanisms linking separate parts of reality. and with type 1 diabetes it’s essential. Trying to change one’s feelings or thoughts may or. In this model of health. It’s a departure from the traditional health model. all of these different ways are good. FIVE-SENSES EXPERIENCING <. The two basic discriminations. As long as they work in the situations in which they’re used. as the matrix doesn’t seek to identify what parts (whether feelings.D1 -> AWAY <. in other words. a model that puts psychological flexibility center stage. 18 TOWARD . One way to introduce the point of view is simply to introduce the two discriminations: between five-senses experiencing and mental experiencing (discrimination 1. or D2). Setting Up the Point of View Work with the matrix always starts with setting up the point of view. and between actions to move toward what’s important and actions to move away from what people don’t want to think or feel (discrimination 2. a number of which are illustrated in this book. flexibility is key. or D1). There are many ways to set up the matrix point of view.D2 -> MENTAL EXPERIENCING Figure 2.1. This essential first step allows people to observe what they’re doing in the context of their whole life—including what they want to move toward. behaviors. thoughts. This is the first step toward psychological flexibility.The ACT Matrix what’s true for each person. As with everything in this model. or chemical imbalances) are malfunctioning or problematic and should be changed. bring to mind some recent action that was a move away or attempt to escape from something you didn’t want to think or feel. As people notice broader aspects of the context than they typically had. Grab a pen and see if you can experience it through each of your five senses in turn (or four.1).Under the Hood: Basic Processes Underlying the Matrix Here’s an exercise to introduce D1. They get stuck because they focus exclusively on unwanted inner stuff. we have taken the first steps toward psychological flexibility. and see if you can experience the pen once more. Here’s a way to introduce D2: Bring to mind some recent action (we’ll define action as something others could have seen you do) that was a move toward someone or something important to you. They become more flexible. Again. this time mentally running through each of the senses. which is another way of saying inflexible. Making these discriminations leads to a greater ability to observe each act in context. Getting Stuck When people enter therapy. they’re stuck. tasting is optional!). people can more readily make distinctions that will make a difference in their life. Toward Psychological Flexibility By setting up the point of view (reflected in figure 2. From this point of view. If you didn’t try it in chapter 1. We call these discriminations. that’s okay. They can notice that they don’t notice a difference. They get stuck because what’s important to them is obscured by their struggle against unwanted inner stuff. Did you notice a difference between five-senses experiencing and mental experiencing? Sometimes people don’t notice a difference. They get stuck 19 . they become better able to notice whether their behavior is in line with what’s important to them and whether it’s workable in their varied life situations. Next. People can get stuck in all sorts of ways: They get stuck because they can’t imagine options other than moving away from unwanted inner stuff. Did you notice a difference between how the toward move and away move felt? Sometimes people don’t notice a difference. Now put the pen away. close your eyes. try it for yourself right now. That’s okay. the gains of treatment are consolidated over the long term. so he’s missed many of his son’s ball games. As a result. our language is about to get somewhat more technical. they become increasingly able to choose actions that move them toward what’s important to them in life. repeated practice. he stops going to his AA meetings and relapses into drinking. she feels so anxious that she seems to forget that making friends is important to her. How Derived Relational Responding Gets Us Hooked As the scary heading of this section might have alerted you. People get unstuck by practicing noticing the two basic discriminations across their varied life situations. John and Jill are unable to recognize that when they’re in conflict. Think of it as stretching exercises that will gradually build flexibility—a yoga of the mind—that requires deliberate. and their actions move them toward better relationships and more satisfying integration into their community. Here are some examples of people who got stuck: Jack gets so hooked by dark thoughts and feelings of despair that he barely gets out of bed. rather than remaining stuck in trying to move away from unwanted inner stuff. They become more psychologically flexible. When Bob feels angry and disappointed with his life. Mike can’t imagine going out when his back pain flares up. 20 . We hope that the preceding pages gave you enough of a taste for what the matrix does that you’ll stick with us through this next section. In this way.The ACT Matrix because they have trouble contacting their five-senses experience and can’t notice how their actions affect other people and their own life. We’ve tried to write in such a way that you can easily follow the discussion even if you aren’t familiar with the technical terms we’ll be using. Getting Unstuck Consistent practice of the matrix point of view gets people noticing the discriminations that will make a difference in their lives. they could choose to engage in an openhearted exchange about what’s important in their marriage and what they could do to improve things. This ensures that their toward moves continue over time. When Amy meets new people. derived relational responding is the result of the way our minds transform five-senses experience into mental experience. For Jack and the others. they bite and engage in away moves. and memories. In technical terms. Hayes. Amy. Technically speaking. and one that’s largely involuntary. Aversives are things that people (and organisms in general) move away from. and John and Jill all get hooked by internal stuff they don’t want. Barnes-Holmes. we live mostly in our heads. the mere thought of a charging bear can make people run away or engage in other actions meant to move them away from that thought and the fear it elicits. it not only relates five-senses experience to mental experience. mental experience largely dominates over five-senses experience. a five-senses experience of a charging bear naturally makes people run away. For example. That’s why people try to move away from the feeling of fear. images. For example. When hooked. Bob. What they do to move away often works in the short term. and as it does so. but also relates all types of inner experience among themselves: thoughts. When people get hooked by the inside stuff they don’t want. In this transformation. It gets going as children learn language. When their hooks show up.Under the Hood: Basic Processes Underlying the Matrix Jack. Derived relational responding can produce so many hooks that people can easily get lost. an action or a comforting thought that serves to move away from the initial thoughts and fears may come to evoke these thoughts and fears. even absent the thought of a charging bear. According to relational frame theory (RFT. they’re behaving under the control of aversive antecedents. Derived relational responding is a very complex process. 21 . people have a hard time noticing the difference between five- senses and mental experience. people react to the derived functions of things rather than simply responding to the direct functions. 2001). feelings. That’s what we call getting hooked by mental experience. As a result. these thoughts. & Roche. This makes it likely that she’ll do it again—at the cost of her long-term life goals. Amy feels relief when she moves away from a person she wanted to meet. Through derived relational responding. Mike. and sensations have (in certain contexts) acquired controlling functions over their behavior through a process known as derived relational responding. Because of derived relational responding. sensations. feelings. Once people learn to speak. Worse. they naturally try to move away from it. mental experience can acquire some of the functions of five-senses experience. new consequences appear. it unwittingly reinforces getting hooked by aversives and responding to them by moving away. This makes it more likely that people will notice appetitives. there’s another kind of mental experience beyond the inside stuff that we don’t want to experience: the things we can notice as being important to us. the matrix sets up a context that includes appetitives. The inner consequences (feeling proud of acting in line with her values) and the outer consequences (people responding to her) of her toward moves made it more likely she’d do something similar again. Because people easily get stuck in the struggle to move away from aversives. In plain language. through five- senses experiencing. they naturally derive things they could do to move toward these appetitives. and so on. Moving Toward Appetitives Thankfully. doubts about their marriage. Most people enter treatment to move away from aversives (primarily mental aversives). In technical terms. called values in ACT. they can start noticing inside stuff that’s important to them. After three sessions with the matrix. Once they start noticing. Amy’s toward moves could be seen as positively reinforced valued actions under the control of appetitive consequences. they start noticing the differences their actions are making. drinking problem. Amy was getting unstuck. so they remain 22 . She noticed people responding.The ACT Matrix Amy’s away moves could be seen as negatively reinforced experientially avoidant actions under the control of aversive antecedents. even when they’re stuck. In so doing. she’s stuck. The goal of the matrix is to help people choose to move toward appetitives. they start noticing that they’re doing what the person they want to be would do. Inside. and she did. Traditional therapy seeks to help people move away from these aversives. We call these things appetitives. people still haven’t learned to move toward appetitives. Appetitives are simply things that people (and organisms) move toward. Once children learn to speak. Amy initiated a few conversations to move toward friendship. That’s the right side of the diagram. Once the aversives are removed. In plain language. pain. And when they do these things. shyness. Outside. They come in asking to get rid of their depressive feelings. Using Derived Relational Responding to Move Toward Flexibility Now we’ll look at the specific processes likely to be activated by use of the matrix diagram. derived relational responding also has a side that can move toward the light. Psychological flexibility is key to long- term change and. reinforced by the social community. even in the presence of unwanted inside stuff. From the point of view of relational frame theory. Second. Actions under appetitive control are long-term patterns of behavior that are. the gains of treatment are maintained in the community after clients stop attending sessions. The matrix stokes this 23 . we believe. Thankfully. The matrix orients toward a different kind of treatment. to improving the effectiveness of therapy and reducing the high relapse rates that stand witness to the failure of the traditional model. for the most part. when Amy responds to the anxiety and self-defeating thoughts that appear when she meets new people by moving away. This has two benefits for the therapist. drastically reducing the probability of relapse. Derived relational responding can help people choose to move toward what’s important. The goal isn’t removing aversives. It’s the dark side of derived relational responding. it’s training the ability to choose toward moves in the presence of these aversives and to notice what happens. She gets hooked and essentially responds as if these experiences were bears she must flee. she’s responding to the derived verbal functions of these experiences. like the force in Star Wars. but it occurs much more broadly.Under the Hood: Basic Processes Underlying the Matrix vulnerable to getting stuck again. and they engage in fewer of the away moves that can lead to impulsivity and a chaotic lifestyle. These verbal functions promote narrow and inflexible behavior. Things get a tad more technical from here on. People who have been reinforced for moving away in this fashion are liable to get stuck again—either in the same place or in some other place—whenever aversives show up again. people’s toward behavior stabilizes over time. This is most clearly seen in people with addictive behaviors (see chapter 5). This is quite close to the definition of psychological flexibility you’ll find in ACT books. First. This is known as the observer position. Jack may come to see his despairing thoughts and feelings as signs of the importance of engaging in activities outside his home. the functions of their experience are transformed. as circumstances and relationships change in new ways. training clients in the two discriminations is all it takes to get them unstuck. The sorting can only be done from a position removed from the content of experience. or both.The ACT Matrix power. Technically. the matrix retrains people by shifting their perspective to an observer position. Shifting to the Observer Perspective From the moment it’s first introduced. From that point of view. they start deriving new relational responses that gradually promote behavior under the control of appetitive consequences. Some consequences are noticed through the five senses. sorting on the matrix trains the observer perspective as learned behavior. 24 . people can notice the stuff they don’t want and the stuff that’s important. This is freedom as B. Amy may still feel anxious and choose to engage in a conversation with someone new. rather. an increase in (positively reinforced) toward moves. use of the matrix point of view itself comes under the control of consequences as people experience a decrease in the long-term consequences of (negatively reinforced) away moves. It trains a (functional contextual) point of view that can be applied across multiple contexts. At its simplest. It’s less that the content of what people experience changes. As the functions of her experience are transformed. Skinner (1972) defined it. With practice. Its visual format is generic and minimally verbal. Some consequences are verbal. Practicing an observer perspective through multiple sortings gradually promotes an increased ability to maintain behavior under appetitive control and to contact positive reinforcement in the presence of more difficult aversive experiences. The matrix therefore provides a visual cue for derived relational responding under appetitive control. F. They can notice both aversive and appetitive verbal functions and the actions that derive from them. Mike may see some of his painful sensations as reminders to attend his son’s ball game. It promotes the deriving of new relations and the transformation of verbal functions to bring behavior under the control of appetitive consequences. Thus. as people notice that they act like the person they want to be. One of the mistakes beginning matrix practitioners can easily make is trying to get clients to sort “correctly. In that case. after a pause. For example. You noticed drinking as a toward move. did you ever notice drinking as an away move?” As clients get better at sorting. They might sort drinking as a toward move—say toward leisure or socializing. emerges. Yet if ruminating can’t be observed through the five senses. does it not belong under mental experiencing? However. calling a friend could be both a move away from loneliness and a move toward friendship. You noticed ruminating as an away move. They first invite clients to perform crude discriminations by helping them identify differences between high-contrast tasks—say. sometimes in the same behavior. Sorting by Successive Approximations Using learning principles. the practitioner just said. At first Jack sorted ruminating into the upper left quadrant of the matrix. At this point it doesn’t matter whether people sort well. “Good. between not going to a party to move away from feelings of inadequacy versus accepting an invitation to move toward making new friends. The principle is for practitioners to reinforce successive approximations of sorting behavior until sorting itself comes under the control of its appetitive consequences. the matrix cues shaping by successive approximations through multiple exemplar training.” Clients with addictive behaviors often start sorting in ways that may seem incorrect. “Yes. the practitioner might simply say.” This runs the risk of getting stuck in arguments or trying to convince clients where a particular experience should go on the matrix. At first we want people to simply engage in the sorting tasks. Then gradually finer discriminations will be trained.” perhaps adding. gradually increasing the difficulty.Under the Hood: Basic Processes Underlying the Matrix Using Learning Principles to Train Broader Derived Relational Responding Matrix practitioners invite clients to practice the sorting tasks cued by the diagram. In such cases clients can be asked to ascribe percentages to the toward and away aspects of the behavior. Practitioners use successive approximations to guide clients to more effective sorting. “And. The practitioner can help by asking who is 25 . the observer perspective. from which the sorting is done. and between five-senses and mental experiencing. First. the client will start noticing the “me” who notices. matrix practitioners coach them in a systematic practice of the discriminations. This move involves two steps. This move contains two important moments of what is known in ACT as defusion: distancing from content (antecedents). Reinforce the behavior of sorting rather than particular responses or ways of sorting. Be on the lookout for it. and did you ever notice drinking as an away move?” Hooks The matrix practitioner invites the client to discriminate and track verbal behavior and its consequences by asking if a particular verbal experience works as a hook for the client and inviting her to notice what she does next. This is done by training the client’s attention to a different aspect of the matrix than the one they’re currently noticing—or hooked by. you noticed drinking as a toward move. The second part of the question in turn is an invitation to track the consequences of behavior (including verbal behavior). “Yes. This is the perspective of “me noticing. A Word of Warning Some clients may give the answers they think the practitioner wants to hear. thus establishing contact with a sense of self that’s distinct from any content or process of experience. So in the example discussed in the previous section. This is known as pliance. Gradually. a practice of D1 is contained in the invitation to notice the hook because the client will then notice mental experience as distinct from five-senses experience. Once clients are engaged in sorting. the practitioner was in effect saying. as it will get people even more hooked and keep them from responding from the perspective of their sorting.” with the sentence being completed by an invitation to further discriminate. and….The ACT Matrix sorting or noticing the differences between moving away and moving toward. and noticing the functions 26 . “Yes.” or self-as-context—the behavior of the observer self. The matrix practitioner seeks to systematically reinforce noticing behavior while avoiding punishing any kind of sorting. always orienting to experience. Gently nudging toward broader noticing is as simple as saying. rather than as purely verbal statements. client behavior gradually transforms from experiential avoidance under negatively reinforced aversive control (of antecedents.Under the Hood: Basic Processes Underlying the Matrix (consequences) of acting upon that content in a given context. both verbal and direct) to behavior under positively reinforced appetitive control (of consequences. they increase their ability to interact with values as ongoing patterns of behavior. the effect of their toward moves on their relationships and their lives. The practitioner also encourages clients to notice. For example. In this approach. making it more probable that clients will derive further toward moves. through their five senses. if John invited Jill to go out for a weekly date night. 27 . clients notice that biting hooks works in the short term but not in the long term. With this training. Summary of the Process Through the training of noticing behavior by means of multiple exemplar training and successive approximations. both verbal and direct). The practitioner reinforces the derivation of these reinforcing functions by asking clients to link toward moves with the values they serve. This allows clients to contact their values and identify actions congruent with those values. When clients practice noticing toward moves in the moment. Furthermore. new aversive functions accrue to getting hooked and engaging in away moves. the role of the practitioner is to orient clients’ attention toward greater flexibility. the link between values and actions helps derive reinforcing functions for their toward moves. Jill might identify being empathic and listening to John as moves toward being the wife she wants to be. In this way. that would be a move toward being the husband he wants to be. This is achieved through the continual practice of noticing or discriminating in the present moment. using the matrix as a cue to train attention toward those aspects of their life context (including verbal aspects) that they aren’t presently noticing or aren’t in the habit of noticing. This promotes derived relational responses under appetitive control. What’s Important The practitioner can also invite clients to discriminate what the person they want to be would do. Left Side Work Let’s start by the left side of the diagram. or so we hope. The matrix increases derived relational responding by providing a visual environment that serves as an overarching network of relations between clinically significant aspects of the client’s experience. Derived relational responding is a result of relational framing. the (largely involuntary) behavior of placing sensory or mental stimuli in frames of preestablished relations that condition the transformation of functions between the framed stimuli. This is achieved by putting aversive private experience 28 . but it’s still manageable. we now provide an even more technical account of how relational framing is put to use with the matrix diagram. as represented by the four quadrants and two main discriminations. that network of relations can become largely automatic and come to control forms of relational framing and transformation of stimulus functions that help people come under appetitive control. hierarchy. The matrix diagram promotes particular types of relational framing (some of which are involuntary) that gradually help client behavior come under appetitive control. coordination. 2001). By making apparent the dynamic links between aversive private experience and experientially avoidant action (away moves). Types of frames include equivalence.. We are moving even deeper into the language of relational frame theory. The matrix diagram dynamically cues movement from psychological inflexibility (the left side of the diagram) to flexibility (the right side). and perspective taking (Hayes et al.The ACT Matrix Forms of Derived Relational Responding Cued by the Matrix For the interested reader who has followed us this far (congratulations!). temporal. the matrix diagram helps transfer some of the aversive functions of these private experiences to experientially avoidant actions. With repeated practice of the matrix point of view. so beware: some technical language lies ahead. opposition. In such cases. even if in the long run they proved ineffective in moving him or her away from aversive private experience. a client with OCD who went running to fight his obsessions noticed that running was also a move toward health and started to run as a move toward. In some cases. bringing them under appetitive control. and bringing into focus its negatively reinforcing functions).” The practitioner can present possible frames of opposition between the away moves and verbal appetitives by asking if these actions have helped clients move toward who or what is important to them. The practitioner can also present frames of opposition between away and toward moves by asking clients if these actions have stopped them from engaging in toward moves.) 29 . and in the long term (usually ineffective. and helping derive aversive functions to those away moves). These temporal frames are also hierarchic. For example. away moves will have allowed the client to move toward something important. new appetitive functions can derive to actions that had previously been engaged under aversive control. but its function changed and it came under appetitive control. rather than as compulsive response to his obsessions. (The moves described above are illustrated in figure 2. When the answer is yes. as “long term” is higher hierarchically than “short term.2. further aversive functions can derive to the away moves.Under the Hood: Basic Processes Underlying the Matrix and away moves in temporal frames through asking questions related to the effectiveness of avoidant action in the short term (typically effective. The behavior remained the same. In the example of the client with OCD. appetitive functions are transferred to actions that were previously under aversive control. or both. In another example of a similar derivation.2.The ACT Matrix - Figure 2. Some possible derived functions working the left side. the practitioner could ask what actions would constitute a move toward something important or. Arrows in boxes represent the direction of derived functions. by deriving that running was a move toward health (itself important). 30 . the reinforcing functions of toward moves are strengthened. ask what or who is important in engaging a particular action. Jill reported feeling oppressed by having to prepare her children’s lunch boxes every evening. As an example of the former. functions derived that served to put running under appetitive control. Right Side Work On the right side of the diagram. by linking verbal behavior under appetitive control (what’s important) to overt actions. Preparing their lunch boxes in the evening made time for that. When asked what the mother she wanted to be would do. she responded that she valued having time with her children in the morning to share the dreams they’d had the night before. conversely. Under the Hood: Basic Processes Underlying the Matrix After being invited to notice whether she made the lunches on the right side (a toward move) or on the left (an away move) over the coming week.3.3. (The two derivations described here are illustrated in figure 2. Jill reported noticing that she prepared them on the right side three nights out of five. In other words. Some possible derived functions working the right side. the matrix can help the appetitive functions of values transform the functions of aversive private experience. verbal appetitive functions had transferred to behavior previously under verbal aversive control.) Figure 2. By putting suffering and values (the lower quadrants) in a frame of coordination and creating a frame of hierarchy with values at the top. 31 . after some matrix work. ACT manuals provide numerous examples of how to link suffering with values in effective ways. The practitioner can actively promote such framing by asking who or what is important behind the client’s suffering. For example. Amy’s uncomfortable feelings and self-doubting thoughts in social situations served to alert her to the importance of relationships and became cues for striking up conversations. Arrows in boxes represent the direction of derived functions. Derivation had transferred new functions to her private experience of shyness. enhancing acceptance and establishing aversive private experience as a possible antecedent of committed action. are represented as they appear in the matrix diagram in figure 2. Finally. people get to adopt an observer perspective toward their content. An Experiential Way of Training Self-as- Context and Perspective Taking By engaging in the sorting tasks. which is akin to self-as-process. through sorting. people necessarily gain distance from their content. 32 . people experience the process of five- senses versus mental experiencing. Those three senses of self.4. they will inevitably see that a part of their context lies on the right side. in other words. sorting undermines the credibility of stories about oneself based on the content of one’s experience. I’m a depressive. or the observer self. Thus. and this will function as a cue pulling them toward appetitives. self-as-context. When Jack buys into his mind saying. This is one of several moves that can serve to promote involuntary derived relational responding that moves clients toward flexibility. known as self-as-content. clients are invited to see if they can spot the matrix in their everyday lives. which are commonly presented in ACT. In practicing the discriminations. Some practitioners even tell clients that they can’t “unsee” the matrix anymore. that’s self-as-content. so no matter how stuck on the left they may feel.The ACT Matrix Promoting Involuntary Derivations Once familiar with the diagram. urges WHO OR WHAT IS IMPORTANT TO ME CONTENT: who and what I choose to hold as important in my life MENTAL EXPERIENCING (PROCESS) Figure 2. she gets hooked by the thought People won’t talk to me. unhooked. perspective-taking framing is at work: people are taking perspective on their experience and behavior from the point of view of “I-here-now” noticing “me-there-then. self-as-process in black. as verbal behavior. memories. which is always implicit in the D2 discrimination (toward versus away moves). touch. hear. is to take the person out of the experience and establish a point of view that’s external to the situation being described—that is. always lags a few milliseconds behind their direct sensory experience. emotions. Making a discrimination is the act of an observer. and self-as-context lies in the center (“Me Noticing”). The fundamental move in the matrix. taste. stories. or smell AWAY MOVES (PROCESS) TOWARD MOVES (PROCESS) ME AWAY WHAT I DON’T WANT TO THINK OR FEEL TOWARD NOTICING CONTENT: thoughts. images. Self-as-content is coded in gray. 33 . When Amy meets new people. and it’s implicit in D2. The matrix and the three senses of self.” even when just noticing that their experience of the moment.4. feelings. bodily sensations. In such moves. The discrimination between hooked and unhooked is D1.Under the Hood: Basic Processes Underlying the Matrix FIVE-SENSES EXPERIENCING (PROCESS) CONTENT: what I can see. rather than engaging in away moves under aversive control. On the left side of the matrix diagram is behavior under aversive control of derived relations (cognitive fusion). On the right side. when these induce behavior that is under the control of these derived antecedents (nonacceptance) and negatively reinforced. in helping children with autistic spectrum disorders acquire broader social repertoires (McHugh. people become better able to stay with difficult experiences. we’re shifting their perspective from one rooted inside the content of the experience being reported (hooked). Matrix and Hexaflex The matrix constitutes a new way of presenting the processes underlying acceptance and commitment therapy. It’s a capacity developed through practice. The correspondence between the two diagrams is illustrated in figure 2. 34 . for example. & Barnes-Holmes. verbally constructed appetitives and consequences (values) can bring behavior under appetitive control (committed action). in using the matrix with clients. as it’s also known) is key in a number of applications. trained through multiple exemplars.The ACT Matrix Perspective taking (or deictic framing. Another way to present the processes is the hexaflex diagram (Hayes. Barnes- Holmes. By repeatedly training this capacity. they learn to derive new responses that will lead toward behavior under appetitive control. & Wilson. The hexaflex is a great conceptual presentation of the psychological flexibility processes. 2009). and made gradually increasingly difficult until a new repertoire is established. 2004). Strosahl. In this way. as discussed above. The matrix represents an application of perspective taking for the purpose of general interventions. Put simply. Twohig. The central hexaflex processes of contact with the present moment and self-as-context correspond to the behavior of noticing and performing the discrimination tasks.5. Perhaps it could help operationalize self-as-context through the process of noticing at any given time the different quadrants and discriminations cued by the matrix diagram. The matrix diagram is a dynamic representation that cues movement from psychological inflexibility (the left side of the diagram) to psychological flexibility (the right side). to one that looks from outside. Bunting. like an observer looking in (unhooked). defusion from acceptance. leading to a potential disconnect between basic science and intervention procedures. For example. for example. and values can cause difficulties. The matrix (in black) and hexaflex (in gray). They are shorthand. It can be exceedingly challenging to tease out. “defused talk. it can be challenging to give basic process accounts of the terms. 35 . A related difficulty concerns research design. may not be a reliable indicator of defusion. especially based on behavioral signs. As an example of the problem. offered as tools to orient practitioners within a seemingly complex and counterintuitive model: functional contextualism. The six hexaflex processes are commonly presented as middle-level terms that don’t precisely map out onto basic behavioral processes. contact with the present moment.” a measure used in some studies.Under the Hood: Basic Processes Underlying the Matrix FIVE-SENSES EXPERIENCING PRESENT MOMENT COMMITTED ACTION NONACCEPTANCE AWAY TOWARD FUSION VALUES SELF-AS-CONTEXT MENTAL EXPERIENCING Figure 2. defusion. Yet committing to terms such as acceptance.5. Its strength is that from the get-go it frames the work of both practitioners and clients in a functional contextual worldview. In some countries and cultures. In this way. From Explicit to Implicit Sorting? We believe that consistent training of the matrix-cued discriminations through multiple exemplars could lead to a form of rapid and implicit discrimination. We may not be at our most effective if. Indeed. Barnes-Holmes.The ACT Matrix We may also become wedded to our terms and thus lose flexibility. In particular. & Vahey. it is our experience that clients who get the matrix and consistently train with it move from explicit or controlled sorting to naturally or spontaneously choosing toward moves. learning to discriminate the felt experience of behavior under appetitive control might gradually orient people toward implicitly recognizing and moving to such behavior without needing to look explicitly through the matrix point of view. even in what had previously seemed intractable situations eliciting away moves. returning people to a more automatic and functional discriminative behavior. There are a number of social contexts in which the terms of the hexaflex carry undesirable functions for the purpose of promoting derived relational responding under appetitive control. in others. “acceptance” carries functions of resignation. This book contains numerous examples of practitioners in various settings changing the terms associated with the quadrants or the discriminations. the term “values” has a socially conservative connotation. we have to specify what these terms don’t mean. thereby potentially preventing one of the dangers that come with the growing popularity of ACT: the use of its exercises and procedures as borrowed technological fixes in the absence of a functional contextual approach. bypassing the 36 . right after mentioning values or acceptance. These are largely interchangeable. Matrix training could be a bridge from valued living through extended and elaborated relational responding to valued living via brief and immediate relational responses. 2012). Consistent use of the matrix viewpoint might thus lead from extended and elaborated relational responses to brief and immediate relational responses (Hughes. The strength of the matrix diagram doesn’t reside in the terms used to establish the point of view. Barnes-Holmes. H. Twohig. and that it might inspire basic researchers to start playing around with the matrix diagram to illuminate it more fully at the basic process level. Relational frame theory: A post-Skinnerian account of human language and cognition..). Varieties of scientific contextualism (pp. It is our hope that this chapter will be of use to practitioners. Strosahl. S. A practical guide to acceptance and commitment therapy (pp. Conclusion As practitioners. (2001). Hayes. C.. Hayes.. M.. (1993). C. R. Hayes. K. C. Sarbin (Eds. Reese. 37 . 3–29). We believe that one of the central modes of action of the matrix is rooted in the way it promotes specific forms of derived relational responding through relational framing. What is acceptance and commitment therapy? In S.. (Eds. or deictic framing. 11–27). Hayes & K. Hayes.Under the Hood: Basic Processes Underlying the Matrix traps of experientially avoidant behavior might restore to our species some of the simplicity of discriminative behavior observed in other living organisms. & Roche.). Bunting. D. (2004). Adopting the matrix point of view provides practice in perspective taking through the behavior of sorting. Strosahl (Eds. C. Through the new derived relational responses the matrix affords. New York: Springer. L.). S. G. W. C. D. K. New York: Kluwer Academic/Plenum. we offer this chapter as our current understanding of the basic processes underlying the use and effectiveness of the matrix diagram as a tool to promote behavior under appetitive control. behavior that has been largely under the control of aversive antecedents can gradually move under the control of appetitive consequences. particularly perspective taking. D. The matrix puts the behaviors of noticing and taking perspective at the heart of clinical work. Analytic goals and the variety of scientific contextualism. thereby facilitating new and more workable derived relational responses. Multiple exemplar training and shaping are at the heart of using the matrix effectively.. & T. In S. Reno: Context Press. S. References Hayes. also known as psychological flexibility or valued living. K. & Wilson. B. 1(1–2). S. In R.). Beyond freedom and dignity. Berkeley: University of California Press. Oakland.. Derived relational responding applications for learners with autism and other developmental disabilities: A progressive guide to change (pp. D. Barnes-Holmes. S. (1972).. A. Barnes-Holmes. Pepper. Skinner. & Vahey. N. B. & Barnes-Holmes. Barnes-Holmes (Eds. New York: Springer. 17–38. Y. D. 281–300). (1961). McHugh.The ACT Matrix Hughes. CA: New Harbinger.standing and training perspective taking as relational responding. L. F. Rehfeldt & Y. (2012).. Under. Journal of Contextual Behavioral Science. 38 . Holding on to our functional roots when exploring new intellectual islands: A voyage through implicit cognition research. C. World hypotheses: A study in evidence.. (2009). PA RT 2 Populations and Settings . . as much as possible. and facilitators on how to use the matrix as a means of introducing the general public to key elements of acceptance and commitment therapy—or acceptance and commitment training. So my commitment to you in this chapter is to speak to you. coaches. in the same way that I would speak to the general public.CH A P T ER 3 ACT for the Masses: Using the Matrix with the General Public Aisling Curtin The matrix can be a very powerful and accessible tool for introducing the general public to functional contextual frameworks. One of my away moves is to overly complicate the conceptual framework. This chapter aims to provide guidance to clinicians. as it is referred to when working with the general public. I hope this will best inspire you to get out there and do this much-needed and meaningful work. and one of my toward moves is to speak about this approach in a way that’s readily accessible to people with no preexisting knowledge of functional contextual concepts. A key element of using the matrix with the general public (hereafter referred to as “people”) is to become aware of our own toward and away moves in communicating these concepts. . educators. Identifying unwanted mental experiences 4. I generally say.The ACT Matrix Introducing the Matrix to the General Public The matrix can be introduced to people in five steps. in your head versus in your life—aren’t that important. Identifying strategies used to avoid pain 5. our job is to help people notice just how much time we spend in our heads compared to the time we spend actively engaged in our lives. Checking workability with three questions 1. Making the Two Primary Discriminations in Terms of Form and Function of Experience Initially. The most common answers range between 90 to 10 and 99. I usually ask them to assign a ratio or percentage to how much time they spend in their head compared to how much time they spend actively engaged in the moment and their life. At this point. Using the Bull’s- Eye Worksheet to establish a baseline and primary focus 3. Once the distinction is clear. Making the two primary discriminations in terms of form and function of experience 2. The exact words you use to make the distinction—mental experiencing versus five-senses experiencing.99 to 0.99 percent of your time in the moment!” After sharing a 42 . inside your skin versus outside your skin. What counts is that your audience can begin to notice this important discrimination. demonstrating the difference between being caught up in their head and actively participating in life. I give everyday examples until each participant fully gets this distinction. that’s amazing that you spend 99. I ask people to self-assess how they’re doing on this continuum.01. and I find sharing personal examples to be most effective. which I describe below: 1. It can be helpful to use humorous personal examples that people can relate to. “Wow. 2. Using the Bull’s-Eye Worksheet to Establish a Baseline and Primary Focus I use Russ Harris’s adaptation of the Bull’s-Eye Worksheet (Harris. 2009. I find that the more personal. Once participants get past the shock of this not meaning what they expect it to mean. I always give personal examples to illustrate that I’m in the same boat. and recreation (figure 3. Strosahl. The action may look the same either way. how much would the actions it recorded you doing be in line with what the ideal you would do? How are you measuring up to how you want to be in this area of your life? Don’t consider how you think I think you should be or how you think your family. I turn to highlighting the primary motivations behind engaging in an activity: aiming to get away from something we don’t want to have or move toward something we do want. 1999) can be particularly useful during this initial phase.” 43 . I care about making the matrix more accessible to people. we look at how universal it is to spend the majority of our time in our head. The function of this action might be not letting down my dear colleagues Kevin Polk and Benjamin Schoendorff or not experiencing the feelings that would come with that. health and personal growth.ACT for the Masses: Using the Matrix with the General Public good laugh. at this moment I’m writing a chapter about the matrix for the public. partner. The only gauge is how you’re doing in relation to how you truly want to be. For example. 2006) to help people rate how much they’re living in congruence with their values in four main life domains: relationships. and relatable my examples are. work or education. A PowerPoint slide with the acronym WTF comes on screen at this point. To clarify what that means. I invite them to notice “what’s the function” (WTF) behind their actions. I say. it will feel quite different if it’s an away move (primarily under aversive control) or a toward move (primarily under appetitive control). Next. fundamentally. “If a video camera were following you around. & Wilson. However. current. humorous.1). Or it could be that I engage in this action because. Dahl & Lundgren. or friends think you should be. The Path Up the Mountain metaphor (Hayes. the more quickly and effectively people can understand this distinction. Recreation Relationships Figure 3. & Eifert. An X far from the bull’s-eye means that you are way off the mark in terms of living by your values. 44 . Forsyth. The Values as a Cube metaphor (McKay. then mark an X in each area of the dartboard to represent where you stand today. Through life events or change of context.The ACT Matrix The Bull’s-Eye Worksheet Read through your values. Work/ Education Health/ Personal growth I have lost touch with my values. I am living fully by my values.1. An X in the bull’s-eye (the center of the dartboard) means that you are living fully by your values in that area of life. Then I ask participants to select one valued area in which they’d like to move closer to the bull’s-eye right now. It likens our choice of which value to pursue in any given moment to seeing one side of a cube. Since there are four areas of valued living. you should mark four Xs on the dartboard. another side of the cube might come to the forefront. The Bull’s-Eye Worksheet. 2010) can help establish focus while also allowing for flexibility. For example. evaluations. while writing this chapter. Identifying Unwanted Mental Experiences Next.2). Our minds are rarely politically correct and can often give us a hard time. The Prompted Bull’s-Eye Matrix Worksheet. Outer World Five-Senses Experiencing Join the DOTS Distraction: Opting out: Valued Domains: Thinking: Family Intimate relationships Substances/self-harm/other: Parenting Away Unwanted Mental or Inner Experiences Troublesome thoughts: Toward Work/ Education Recreation Friends Education Work Recreation Spirituality Uncomfortable bodily sensations: Citizenship Health/ Personal growth Health Relationships Mental Experiencing Inner World Figure 3. the top three thoughts I’m struggling with are I have no idea how to write this. I provide examples of common thoughts people struggle with. I walk participants through a worksheet I created based on the matrix (figure 3. Then I elicit further examples from participants. When I ask participants to write their three thoughts. 45 . Write down as many of your thoughts as possible. I invite them to identify the top three thoughts they struggle with in that area. exactly as they would appear in your mind.2. I provide a simple definition: “Thoughts are often strings of words that generally involve judgments. others. Encouraging participants to remain focused on the main valued domain they’ve chosen.ACT for the Masses: Using the Matrix with the General Public 3. or the world. or comparisons of ourselves.” Again humor and personal examples help normalize this experience. There’s no point in trying. such as I’m not good enough. I bet most of the other contributors will have PhDs. and Things don’t work out well for me. we look at participants’ top three away moves in four categories: Distraction Opting out Thinking Substances.The ACT Matrix and My chapter will probably be the one that needs the most editing—if they even accept it. I use a simple definition of emotions: “Emotions are generally words that can sum up how we’re feeling overall and aren’t tied to a particular part of the body. since these are often regarded as inner experiencing in matrix work. Time permitting. or bodily sensation. we might look at unwanted urges and memories. even when it’s difficult. Initially. emotion. and bodily sensations mixed up. The key is to model awareness of and willingness to share whatever my experience is. Next. 46 . Identifying Strategies Used to Avoid Pain Next. emotions. using Russ Harris’s Join the DOTS approach (Harris. and other strategies The DOTS are outlined in the top left quadrant of my matrix worksheet.’” Finally. I ask participants to look for the top three emotions that they get hooked by or entangled in trying to avoid in the valued domain they’re working with. Examples would be ‘sad’ or ‘anxious. emotions. people often get thoughts. Labeling accurately is important because participants will later learn different ACT strategies they can apply depending on whether they’re struggling with a thought. 4. a feeling. and bodily sensations mixed up. self-harm. I ask participants to identify the top three bodily sensations they most want to get rid of in that same valued domain. Our job is to reinforce their willingness to share and then help them more accurately label what they shared as a thought. 2009). I always allow enough time for participants to jot down their top three unwanted experiences in each category. or a bodily sensation. It can be helpful to use different colors of pens for each category of unwanted mental experiencing to underscore the differences. Parsing in this way keeps people from getting thoughts. therefore. thinking is how we respond to such thoughts—for example. Nobody could accuse you 47 . we look at the category “substances. by ruminating. text messages. suppressing them. e-mails. Therefore. I define “opting out” as “avoiding people. particular people. Have any of the strategies in the top left quadrant permanently gotten rid of any of the unwanted experiences in the bottom left quadrant? The answer is inevitably no. food. food. and so on. TV. Normalizing this experience is important. Similarly. I often say. or job applications or other opportunities. Checking Workability with Three Questions Next. At this point. Giving personal examples can be extremely useful here. or engaging in positive thinking. such as avoiding calls. activities. and prescription medications may be included as substances if used in an attempt to avoid some internal experience.ACT for the Masses: Using the Matrix with the General Public For distraction. self- harm.” I use empathy and humor to help people feel more comfortable in identifying their top three strategies in this area. caffeine. I help participants assess workability using three key questions: 1. many. versus mindlessly consuming in an attempt to numb or distract ourselves. I explain that in ACT. it may include behaviors like ignoring people or lashing out.” I give common examples. and other strategies” from a functional point of view. 5. self-harm includes any activity that causes the person harm or damage in the long term. such as the thought I’m not good enough. many things. “It seems like all the people in this room have tried many. I mention common distraction strategies such as the Internet.” Whereas thoughts are generally strings of words that appear in our mind that we have little or no control over. challenging them. I draw a distinction between thoughts and the category “thinking. I define “distraction” as “any activity we engage in to try to get away from an unwanted mental experience. I try to help participants become aware of the difference between having a piece of chocolate or a glass of wine to savor it and the company we keep in those moments. I then elicit three examples from participants. or situations in order to minimize or avoid feeling pain. 2011). or opening up Defusion and unhooking. do you move closer to the bull’s-eye or farther away? The answer is typically farther away. Integrating ACT with the Matrix ACT is about connecting with the here and now and the things that matter most to us.” 2. Maybe it’s just that you’re playing a rigged game. adjusting my descriptions to meet participants’ needs: Connection. & Wilson. when you use these strategies rigidly or excessively. do they make your unwanted mental experiences better or worse? The answer is usually worse. or watching your thinking 48 . 3. I introduce the six core processes of ACT that the matrix can target. or being here now Expansion and compassion. I also explain that the matrix and various ACT strategies are tools to help us accomplish two things: to learn strategies to manage unwanted mental experiences and unworkable strategies more effectively (the left side of the matrix). This is a means of using the matrix to illustrate the ACT process of creative hopelessness (Hayes. and accepting what lies outside of our personal control. Strosahl. 2009). relationships. when you use these strategies rigidly or excessively. Physical metaphors can be quite helpful in illustrating that avoidance is the opposite of acceptance. In general. For the purposes of public workshops. At this point. I generally refer to the six processes as follows (adapted from Harris. and things that matter most to us as well as to take action to move toward the bull’s- eye in the areas that matter most (the right side of the matrix). taking meaningful action in our lives. and to identify the people. In general.The ACT Matrix guys of being lazy. we look at the importance of recognizing that these strategies aren’t workable. and I explain that the matrix is a tool to help us check in with our current strategies and assess their relative effectiveness. bodily sensations. Are these actions that help bring you closer to who and where you want to be. compassionate mode. Watching reactions to thoughts. Imagine that you’re watching a video of yourself as you become hooked by these thoughts. A transcript of the exercise is downloadable on the book’s website: http://www. I’d like to invite you to connect to the actions you engage in when you’re in avoidance mode. we generally go into one of two modes: avoidance mode. Cultivating Mindfulness At this point. or an allowing. Notice any difficult or unwanted emotions that might arise within you. or doing what it takes I developed and sometimes use the Matrix Mindfulness Exercise to connect with ACT processes through the matrix. This allows us to check in on these processes from a vantage of workability. Gently become aware of any thoughts that might arise in the form of judgments. and comparisons in your daily life. Watching reactions to emotions. or do they take you further away? Rest in the knowledge that the vast majority of us engage in actions that take us further away when we’re in the midst of avoidance mode. evaluations. or seeing the bigger picture Values. and behavioral patterns in both their internal and external worlds. If you’re willing and choose to do so.ACT for the Masses: Using the Matrix with the General Public Observing self and perspective taking. 49 . The underlying question is “Does engaging in this pattern and acting in this way help me move toward the bull’s-eye.newharbin ger. emotions. I generally introduce mindfulness exercises. and simply notice whether you engage in actions that help bring you closer to who and where you want to be or whether you engage in actions that take you further away. as I find them a useful means of helping people connect to the principles of ACT and the matrix. When these emotions arise. or knowing what matters Committed action. Participants become more aware of their habitual thoughts. or does it take me farther away?” Here are some suggestions for guided mindfulness exercises that can fulfill this function.com/29231. guilt. I ask participants to come up with a couple of examples of thoughts they might get hooked by and what their toward and away moves might look like on a video camera. do you see yourself doing things that brought you closer to who and where you want to be. there’s a reality gap—a discrepancy between what we want and what we have in our lives. and things that matter most to you. fear. (You can repeat this exercise with more painful reality gaps as you learn and integrate these skills. Here again. Now connect to one small thing that you can do in the next couple of days to help you move closer to who and where you want to be. I 50 . I’d like to invite the you that is right here right now to imagine asking the you in that reality gap “What is it that you need?” Simply listen and breathe… (Pause and repeat the question twice. that this is part of being human. disappointment. no matter how brief. you were moving closer to or further away from who and where you want to be. Cultivating self-compassion. see ourselves doing things that take us further away. when we feel strong unwanted or difficult emotions.) In this moment. Once we have two examples. Notice what difference this small action might make for you and the people. and memorable. For example. Do you see sadness. in these moments. myself included. Simply notice whether. I’d like to invite the you that is right here right now to imagine looking into your eyes in a moment of vulnerability earlier in your life. Cultivating committed action.) See if you can extend some small gift of kindness and compassion to yourself exactly as you are. Cultivating Defusion The matrix and its primary functional discriminations can also aid in gaining a functional understanding of how each of the six core ACT processes work. Simply notice what you can see. with regard to defusion. or some other emotion? From the vantage point of the you that is right here right now. As best you can. relationships. bring to mind a moment when you felt a reality gap. humorous. the key is using examples and illustrations that are personally relevant. Often. and we are still worthy of love and connection. or do you see yourself doing things that took you further away? Rest in the knowledge that the vast majority of us. resentment. regret. Choose a moment that feels okay for you to look at in this context.The ACT Matrix Now notice any moments. looking back to that you in that moment of difficulty. when you brought a more compassionate and allowing approach to your experience. she stays at home and spends the evening surfing the Internet. I demonstrate this by role-playing Ann. “I’m too anxious. I might panic. whose lack of confidence is a barrier to going out. 51 . As Mary. who felt worse but engaged in a toward move anyway? People almost always get this and realize that from an ACT perspective. and Mary. I might pretend to be the Roadrunner and bleat. I find that demonstrating defusion in this way often stays in people’s minds because these strategies are a bit on the wacky side. and she decides to go out anyway because it’s a move toward her values. and I’m not confident enough to do that. As Ann. and she feels so much better that she decides not to go out. it’s all about living better—engaging in more toward moves—rather than feeling better by numbing or moving away from unwanted thoughts and feelings. However. Common thoughts that people get hooked by include I’m too anxious. participants choose to have me sing one of the thoughts to the tune of “Happy Birthday” and to say the other in the voice of a cartoon character. Instead.ACT for the Masses: Using the Matrix with the General Public offer to demonstrate a defusion strategy for each example and invite participants to choose which ones I’ll demonstrate. I then say that using this defusion strategy makes Ann laugh too. For each unhelpful thought. who felt much better but didn’t engage in a toward move. “Beep beep!” This generally gets people laughing. the toward move would be engaging in the feared action if doing so is consistent with the person’s values. Generally.” I then say that after using this defusion strategy Mary feels even worse and less confident than she did before. Was it Ann. Although I might give people handouts with a variety of strategies for each of the six ACT processes. I might panic!” in a high-pitched voice while running across the room and saying. whose anxiety is a barrier to going out. I might sing the thought I’m not confident enough to do that to the tune of “Happy Birthday. and the away move would be distracting by doing an activity not guided by values or opting out of a values-consistent activity. I then ask who did defusion from an ACT perspective. this strategy gives her a chance to connect to her values. or was it Mary. We learn about the nature of the mind and shift the primary focus of our attention to our actions—that which is within our control. the matrix helps us and the people we serve come back to the functional contextual basis of ACT again and again. they can still choose to live in a values-consistent way. Relational Frame Theory Through the Lens of the Matrix Through experiential exercises augmented by including matrix components. to become conscious. With the matrix. or month) is. However. The fact that we can relate anything to anything else becomes more apparent with repeated use of the matrix and 52 . and ourselves. redefine what a bad day (week. In this way. ACT exercises are augmented by continuously looking at toward and away moves and increasing awareness of how certain contexts (both internal and external) may shift the likelihood of engaging in particular actions. we can choose to act in a different way in any context. Using tracking over time. outside of a religious context (to accept the things we cannot change. people (ourselves included) become increasingly aware of how language is a double-edged sword. empowered choosers. me included.The ACT Matrix Back to the Functional Contextual Point of View Essentially. we help people move away from rigid rule following. creating lives that matter through ongoing tracking—noticing whether applying a particular rule is effective or not. We are ultimately trying to help others. The challenge within the Serenity Prayer. This approach has helped many people. becomes increasingly workable as the matrix helps us see exactly what is and isn’t within our control. and to have the wisdom to know the difference). even in the face of unexpected or undesired life events. and what constitutes a toward move in one context might be an away move in another. or pliance. We learn that it is not mental experiences that are fundamentally problematic. to have the courage to change the things we can. live more in the top right quadrant of the matrix. people can become aware that. I know for certain that on that day I would think of my brother Shane.g. Even though I have the capacity to read directions. or who probably have a better relationship history.. I give personal examples of comparisons that I’m making in that moment. To show how randomly applicable language can be and how anything can become bad. & Roche. And with this awareness 53 . I can notice people who I believe to be more intelligent or attractive than I am. fit into at least one of those categories. Something seemingly minute in my environment or context. I generally do this work by looking at how words have the capacity to make both our past and our future very much alive in the present. can trigger an internal experience within me that can make a reality gap in my life very evident and very painful. and book flights for conferences (and occasionally. Unfortunately. do this well). I’d think about what age he would be. and comparisons become evident. Supplementary metaphorical and experiential exercises can be used in conjunction with the matrix to illustrate relational frame theory (RFT. but not always. I would feel his loss afresh and experience a wave of sadness. we are able to read directions and understand warnings whether in written or auditory form) and the ways in which it leads to suffering (e. 2001).g. whether he would have a partner. evaluations. something that might not even be noticeable to someone else. I often share a personal story. constant comparisons and how a single aspect of our context can remind us of a time when we felt incredibly sad or anxious).. Barnes-Holmes. who died tragically almost fifteen years ago. We know from RFT that values and vulnerabilities are two sides of the same coin. and how he would have felt on that day. I believe that the matrix normalizes this experience and shows it clearly. I find it important to look at both the ways in which language works well (e. and if I ever were to get married. even to someone I deeply care about and could see myself spending my life with. Hayes. reason giving. It’s about how I’m not married. reading this chapter now.ACT for the Masses: Using the Matrix with the General Public also when the matrix is used in a large group. In any given room. follow instructions. I have the capacity to suffer in a way that animals and preverbal children don’t. I’m willing to bet that you. And I know that in that moment. So with language we have the ability to make contact with both incredibly painful and extremely pleasant elements simultaneously. you’re probably so busy comparing yourself unfavorably to others that you can’t fully connect with that. Verbal processes such as judgment. In fact. Personally. the matrix puts the principles of RFT into action. or toward actions). 2009). The matrix is a powerful tool to help people become aware of their clinically relevant behaviors (CRBs). caring. 54 . and the words “clinically relevant. (See chapter 4 for more on FAP. For me. Do I get sucked into these verbal processes and let them push me around? Or do I compassionately notice how these processes impact me and mindfully choose an action that brings me one step closer to the bull’s-eye? In this way. Functional Analytic Psychotherapy from the Matrix Perspective One of the things I love about functional analytic psychotherapy (FAP) is that it sees nothing as absolute or fixed. FAP has helped me be more authentic. For the rest of us. Kohlenberg.The ACT Matrix comes an opportunity for choice. or away actions) and CRB2s (improvement. may seem somewhat daunting to a lay audience. the authors give a number of descriptions of FAP from different sources. So I feel liberated to give my own definition of FAP and share what it means to me and how I feel it’s relevant to people. Fellow practitioners have asked me about the differences between ACT and FAP. I stick to the matrix terms “away” and “toward. which are divided into CRB1s (problematic. genuine. rather than as therapy. & Kanter. however. In the opening chapter of A Guide to Functional Analytic Psychotherapy (Tsai.” while extremely useful in clinical settings. and loving in my most important relationships. FAP is about looking deeply at the ways in which we relate to others and honestly reflecting on whether those are in alignment with how we want to relate to others and ourselves in the world. which I highly recommend to anyone wanting to delve a little deeper into the world of FAP.) With the general public. I firmly believe that FAP supercharges any intervention we lead. I believe that some people who are extremely functionally sensitive and courageous both in their lives and in the way they interact with others or clients may not need FAP.” as ACT in a public context is always considered acceptance and commitment training. or must. should. The first thing and most important thing isn’t something that can be taught. (2006). no matter how many hours I may have spent on it. you can help people make meaningful changes in their lives. In my opinion. and it constantly challenges and encourages you to go one step further outside your comfort zone—and that’s where the magic happens. J. CA: New Harbinger. an approach that helps them learn strategies to manage thoughts and emotions more effectively while moving toward a life that really matters is infectious. This chapter isn’t about knowing everything you need to know to bring the matrix to the general public. Oakland. live. At a time when people feel that they’re doing more and more while enjoying less and less. It’s a willingness to look at the barriers to bringing this work to the public that you might face. T. and finding a reason for doing so that’s big enough that you would choose to take one step closer toward shining brightly—not because you have to. FAP can help you maintain an overall functional contextual perspective that’s sensitive to the most minute changes in interpersonal contexts.ACT for the Masses: Using the Matrix with the General Public I include this brief discussion of FAP because I believe that this approach will greatly accelerate the changes you can promote in your own life and in the lives of people with whom you share this approach. Conclusion This chapter will hopefully serve as a reference point on how to integrate the matrix into work with the general public. This is far more effective than any particular strategy I’ve developed. any ACT or matrix exercise that looks deeply into how we relate to others and the impact this has on relationships is informed by FAP. & Lundgren. the more people get it and implement it in their own lives. References Dahl. It has been my experience that the more I model. just maybe.. and breathe this approach in my own life. but because this work is worth having all of that stuff on the bottom left side of the matrix if maybe. Living beyond your pain: Using acceptance and commitment therapy to ease chronic pain. 55 . eat. H..The ACT Matrix Harris... & Kanter. R. Hayes. C. Hayes. (2009). A guide to functional analytic psychotherapy: Awareness. (2001). B. love. J. Strosahl. (2009).. G. K. K. R. New York: Guilford. CA: New Harbinger. S.. New York: Springer. C. New York: Guilford.. G. 56 . & Wilson. Relational frame theory: A post-Skinnerian account of human language and cognition. Oakland. J. M. Oakland. S. K. Forsyth.. Acceptance and commitment therapy. D. and behaviorism. M. D. C.. Barnes-Holmes. (2010). (1999). Your life on purpose: How to find what matters and create the life you want. & Wilson. K. Kohlenberg. J. D. (2011). courage. S... Acceptance and commitment therapy: An experiential approach to behavior change. W. P. CA: New Harbinger. McKay. Strosahl. & Roche. & Eifert. ACT made simple: An easy-to-read primer on acceptance and commitment therapy. second edition: The process and practice of mindful change. G. New York: Kluwer Academic/Plenum. Hayes. Tsai. We’d get lost in our heads (and our clients in theirs) and find ourselves moving .CH A P T ER 4 You. we noticed occasionally getting stuck in a very “mind-y” place.. Me. we describe how the matrix can serve as a powerful tool for integrating a relationship-centered therapy—functional analytic psychotherapy (FAP. 1991. which in turn has promoted broader psychological flexibility and values-driven behavior. We’ve been using the matrix diagram in our clinical and therapist training practice since it was first devised by Kevin Polk. used as a tool to present and train individuals in a functional contextual viewpoint. & Loudon. Kohlenberg. especially when doing defusion or values work. and Mark Webster. In this chapter. Tsai. Kohlenberg & Tsai. can also serve to integrate contextual therapies other than acceptance and commitment therapy. et al. and the Matrix: A Guide to Relationship- Oriented ACT Benjamin Schoendorff and Marie-France Bolduc The matrix diagram. We’ve found it incredibly helpful in getting our clients and trainees to adopt a functional contextual viewpoint. In our ACT practice. Jerold Hambright. Tsai. Holman. 2009. Kanter. Kanter. 2012)—into ACT-based individual and couples clinical work. Kohlenberg. Kohlenberg. & Goering. as poor quality of relationships is a major risk factor for depression (Teo. For example. Jack. as well as the effects client behavior had on us. whether through the resulting avoidance of relationships or because it leads them to pursue ineffective ways of seeking support. Sheldon. FAP is a relationship-centered contextual therapy that focuses on the therapeutic relationship as the vehicle of clinical change by means of reinforcement of improved in-the-moment behavior. and is a predictor of recurrence (Vittengl. Whisman. This is unfortunate. FAP alerted us to the importance of noticing interpersonal functions in the room. The outward forms of the inner struggle often make others move away.The ACT Matrix away from a deeper connection with our clients and their suffering. 2000). has seen his friends gradually distance themselves and lose touch. A Tool for Integrating ACT and FAP We’d already started integrating FAP into our ACT practice when we adopted the matrix diagram. Clark. is a powerful intervention to help clients develop a more accepting relationship with their personal experience. 2004). we also noticed that it didn’t always get at the roots of our clients’ interpersonal difficulties. whereas social support offers protection against depression 58 . Soon we discovered that it could serve as a tool to integrate ACT and FAP. The Importance of Interpersonal Processes Difficulties in close relationships are implicated in many psychological disorders (see. Choi. for example. progress in interpersonal effectiveness didn’t always follow. & Jarrett. FAP offers the therapeutic relationship as a training ground for improved interpersonal behavior— for both clients and therapists. 2009). Clark. is correlated with depression severity (Vittengl. & Jarrett. Struggling against unwanted inner experience isolates people. & Valenstein. It helped us better track and make use of the effects of our behavior on clients. who is depressed and expresses only dark thoughts. Though clients came to struggle less with inner experience and engage in more valued actions. 2013). as presented in the classic manuals. hopes. at least as we practiced it then. and aspirations. Although ACT. Cooper. The matrix invites people to discriminate between actions engaged to move toward what’s important and actions engaged to move away from inner suffering. When the question “What’s important to you in life?” draws blanks. and the Matrix: A Guide to Relationship-Oriented ACT (Peirce. relational values are at the center of most people’s lives. In real life. In therapy as in real life. Leader. and how they interact. and puts workability center stage because it helps sort behavior in terms of its effectiveness in moving toward what’s important. there is rarely just one matrix in play.You. & Mudar. & Klein. & Pistorello. both aversive (suffering) and appetitive (values). 2010). Me. The matrix is thus ideally suited to helping both client and therapist notice interpersonal processes. 59 . the therapist’s matrix. which according to the ACT model is one of the main sources of psychopathology (Boulanger. there is the client’s matrix. Frone. and valued actions. 2000) and is a predictor of recovery from depression (Lara. 1997). Hayes. It enlarges the context of interest to include inner experience. in session) by moving toward values or away from unwanted inner experience. In therapy. The matrix draws attention to the clinically relevant aspects of the context: those that play a role in maintaining problematic behavior and those that can contribute to flexible values-driven behavior. people’s matrices interact with others’ matrices. Russell. The matrix is also an effective tool for helping clients notice in session their inner experience and whether they respond to it (again. for a highly social species such as the human. 2004). It helps discriminate between experientially avoidant behavior. which in ACT are key to a meaningful life (Wilson & Murrell. Furthermore. Modeling Intrapersonal and Interpersonal Processes The matrix is first and foremost a way to establish a functional contextual viewpoint. the question “Who’s important?” nearly always works. The matrix point of view helps clients sort their behavior between sessions and. or CRB2). The two types of CRB map out neatly onto the horizontal axis of the matrix. or CRB1) and in-session instances of improved behaviors that could make a positive difference when generalized to the client’s life (clinically relevant behavior 2. with CRB1s on the left (away moves) and CRB2s on the right (toward moves). promotes generalization of matrix sorting to clients’ everyday lives. 60 . whether away moves (CRB1s) or toward moves (CRB2s). leading to a stronger sense of connection with others (desired C). The matrix is flexible enough to allow either outside events or inner experience to be identified as either antecedents or consequences of target behavior.The ACT Matrix The Matrix and Functional Analytic Psychotherapy FAP focuses on discriminating between in-session instances of problematic day-to-day client behaviors (in FAP called clinically relevant behavior 1. So Rosa might identify the familiar antecedent of feeling misunderstood and instead respond to it by sharing her feelings (improved B). by increasing the functional similarity between in-session toward moves and away moves. Promoting Generalization The relevance of the matrix to FAP work extends outside sessions to problematic or improved daily-life behaviors. In-the-Moment Functional Analysis FAP sees clients’ ability to identify the antecedents and consequences of their behavior as key to progress. with the consequence that her relationships feel unsatisfying (C). As clients identify the three-term contingencies evoking their behavior. Using the matrix can be of great help to clients in performing CRB3s. Let’s consider a client named Rosa. they open the door to responding to the antecedents in new ways and moving toward desired consequences. who might identify feeling misunderstood (A) as an antecedent to the behavior of withdrawing (B). Clients are encouraged to perform three-term ABC (antecedent-behavior-consequence) analyses of their behavior (FAP terms such analyses CRB3). Using the Matrix in Relationship- Centered Clinical Practice Clinicians wishing to concentrate on present-moment processes can invite clients to focus on matrix sorting tasks in the moment. Me. Kohlenberg. It promotes generalization of CRB by inviting clients to notice away moves and toward moves in daily life and. In addition. either form of analysis can be helpful. Kanter. The FAP Rap From the first session. more generally. Depending on the context. the therapeutic relationship is thus established as a model of how an intimate relationship that works looks and feels. It’s also an opportunity for clients to give informed consent to relationship-centered work. and the Matrix: A Guide to Relationship-Oriented ACT Thus. neither client nor therapist needs to get stuck on a given model of causality and argue about whether feelings and thoughts or outside events “cause” behavior. The same holds true when using the matrix. known as the FAP rap (Tsai. CRB3s are also a way to promote generalization. & Waltz. especially as they relate to the therapeutic relationship. we give clients a rationale for relationship- centered work: “The difficulties and unpleasant thoughts and feelings you struggle with might show up in here. between us. about our work or our relationship. to spot the matrix in everyday experiences.You. Beyond allowing clients to practice more effective interpersonal behavior and get reinforced for it. 61 . is central to setting the stage. The therapist helps clients gain flexibility in their functional accounts by orienting them either to outside events or to inner experience. 2009). For FAP. Are you willing to work in this way?” This rationale. it also represents an opportunity to work in the moment with what’s showing up so that you can learn ways of dealing with it that will help you go where you want to go and get what’s important for you in life and in your relationships. This is not only normal and acceptable. we spell it out in a letter. So it will be important for us to pay attention and share when these things show up in here. we introduce the matrix. If you’d like. We also ask clients to name one away move and one toward move we could see them doing in therapy (CRBs). making it hard for him to notice who or what is important—except as rigid rules full of “have-tos. we can look at how this works for you. who tries his damnedest not to feel what he’s feeling. Spiky and Flexi Playing around with the matrix. Flexi feels the same difficult stuff as Spiky. we ask clients to name someone or something important to them.” Spiky’s struggle makes others move away.1). He’s just more flexible around it and makes space in the service of moving toward who or what is important to him. allowing us to contact who or what is important and choose to move toward it. & Bolduc. we derived cartoon characters embodying moving away and moving toward: Spiky and Flexi (Schoendorff. “We all have things that are important to us and things that make us suffer in life.The ACT Matrix Introducing the Matrix Next. 62 . When people move away. A quick and effective way is to show clients a matrix diagram and say. they often become like Spiky. we can choose to slow down and make room for whatever we’re feeling. or some inner difficulty or suffering that has been troublesome. We conclude by asking for permission to ask if particular in-session behaviors constitute an away move or a toward move.” Next. There are a number of ways this can be done. He tenses up and gets all rigid and spiky. see figure 4. Grand. This is what Flexi does. When we notice ourselves getting spiky. Then we may invite them to identify at least one action they do to move away from their suffering and one action they could do to move toward what or who is important. It also makes him more vulnerable and easily entangled with spiky people and spiky things. 2011. What these are and how we function with them is unique to each of us. You. and the Matrix: A Guide to Relationship-Oriented ACT Figure 4. They also nicely illustrate the interpersonal functions of struggling. allowing him to contact what’s important in the situation and choose toward moves. and the functions of acceptance and valued living. Spiky and Flexi. thus creating further spikes by struggling. 63 . Flexi makes room for what he doesn’t want to think or feel. Me. which make others more inclined to move closer and seek deeper connection. which makes others move away or enables only connection in superficial ways. The spikes represent suffering as well as moves away from suffering.1. Whereas Spiky seeks to contract his experience of what he doesn’t want to think or feel. We’ve found that these characters offer an intuitive way for clients to get a sense of the felt difference between away moves and toward moves. I’m noticing some Therapist: W tension in my throat. it makes me feel hopeful that I can help you. In these dialogues. or toward move) that can be reinforced. Client: I don’t think therapy can help. this can help clients better evaluate the impacts they have on others. Bearing in mind the potential aversive effects of revealing too directly the aversive functions of clients’ CRB1s. The therapist let him see the interpersonal functions of that statement and offered a possible 64 . and I don’t believe you’d care if I weren’t paying you. the client was first moving away from despair by voicing disbelief and pushing the therapist away. the therapist is a woman. Nothing will ever work. and the client is a man. I can see that it’s because things are so painful for you right now that you’re being like Spiky. with a dialogue. hen you say that nothing will work. One effective strategy when addressing client CRB1s is to distance somewhat from the emotional reaction the client’s behavior elicits and immediately present an alternative (CRB2. Therapist: When you say this.The ACT Matrix Letting Clients See Your Matrix When clinicians are willing to be open about their own matrix and to authentically reflect the effects of client behavior on them. shame. and let me know that you too are committed to our work. and also some sadness. Do you think something similar might show up for other people in your life? Client: Sure. I wonder if you’d be willing to let your mind say. or away moves. Everybody’s dropped me. I don’t believe anything can help. In this dialogue. clinicians will carefully choose how to titrate such reflections. We’ll illustrate this technique (and many others in this chapter. Client: It’s nice to hear you say that you’re committed to being there for me. And now you want to drop me too? Therapist: No. and irritability. it’s important to me to be there for you. I have the thought that I don’t know how I can help you. it’s actually really hard for me to accept other people’s help. clinicians can help clients pay attention to CRBs showing up in the room and the clinical relationship by asking if an in- session behavior is a toward move or an away move. and a courageous one.. for you. Therapist: Would you say that what you said just now. We’ll illustrate this with a continuation of the previous dialogue. I want to support you in doing more toward moves if that’s your choice. the therapist then suggested a possible toward move (CRB2). and the Matrix: A Guide to Relationship-Oriented ACT parallel to problems in day-to-day life. 65 . When the client produced a toward move approximating the suggested CRB2. thus orienting him to a possible CRB1. I guess I wish I could do it more so I didn’t push people away. was an away move or a toward move? Client: I guess a toward move. I know that. the therapeutic relationship and what happens moment to moment between client and therapist can become an effective training ground for more workable relational behavior based on authentic reactions by both client and clinician. So what further toward move could you do right now? Client: I guess I could ask you to give me some clues as to what I can do when I feel so down that I just want to curl up and die. In this way.You. the interpersonal functions of the toward move). Stating her values. the therapist sought to reinforce it by letting the client see how she felt (i. Therapist: What was important to you there? Client: Well. Therapist: I felt like you were letting me come closer when you said that. Using the Clinical Relationship for In-the-Moment Sorting Broadly speaking. Me. which he validated. asking for help—and then accepting it—is a toward move.e. that it felt nice to hear that I was committed to helping you. (Presents an activity record sheet that invites clients to note if an action was a toward or an away move. We commonly use the Hook metaphor.com/29231. Good! For me. or a bodily sensation. they’re asked to notice what do they typically do next: a toward move or an away move. Noticing the hook helps me notice what I tend to do next. Defusion The matrix also helps promote defusion and can easily be blended with traditional ACT exercises. How about you? 66 . an emotion. what do you do next? Client: I become sad and angry.The ACT Matrix Therapist: I do want to help. or for the same client in a different context. I may just shut down or propose an exercise right away. and the therapist seeks to reinforce it by responding in a natural way to the client’s request. Good! And when this hook shows up. is a hook for them. whether it’s a thought. which is generally a toward move. Clients are invited to notice if some aspect of their inner experience. the worksheet can be downloaded at http://www. Note that for a different client. Therapist: So that’s what hooks are. which the therapist may not want to reinforce. asking for help might be an away move.newharbinger. If I don’t notice the hook. and I just want to shut the whole world out. What do you think your hooks were earlier? Client: A big hook for me is that nothing’s ever going to change. and here’s something that’s known to be effective for depression. If it is. Therapist: You notice what you do next.) The client has identified asking for help and accepting it as a toward move (CRB2). Therapist: You noticed that hook. the hook is that I’m not a good enough therapist. and notice if I can see what the person I want to be would do next. using the question “What do you do next?” This highlights the behaviors that follow from biting the hook of that particular content and thus effectively promotes CRB3. The Hook metaphor contains the two important steps of defusion: noticing thoughts or emotions as thoughts or emotions. Like “People don’t care about me. I don’t know if I could do it out there. would you say that’s more like Spiky or Flexi? Client: Like Flexi. I think the hook doesn’t come alone. and getting at the function of individual thoughts or emotions in their particular context. and the Matrix: A Guide to Relationship-Oriented ACT Client: Hmm. you noticed that. I withdraw…get crabby.” Therapist: Ouch! Painful hooks. And what would the person you want to be do when these hooks show up? Client: Not push people away. Therapist: Okay. so… Therapist: Seems to me you’re biting less right now. Client: (Laughs. Therapist: How about seeing if you can notice hooks and what you do next between now and next week? Client: Sure. but that’s only because you’re helping me. and 67 . Acceptance Inviting clients to describe what shows up in the lower left quadrant of their matrix is an effective way of promoting acceptance. It’s when I bite that I become like Spiky. Me.) Yeah. The character Flexi is also a versatile image for promoting and discriminating acceptance in the moment. thereby affording some distance from them. There are many others on the line. And what do you do next when these show up? Client: The same. Therapist: It’s great to see you make space for these hooks without biting.” and “I’m all alone anyway. Therapist: When you talk about noticing your hooks and not biting. See if you can notice how you do that.You. as if cut off from the rest of their body. When asked to describe their feelings or bodily sensations in an aversive situation. one of us (Marie-France Bolduc) thought of adding a layer of experience around the matrix (see figure 4. In working with this population. The matrix with an added layer of experiencing. In the upper part of the matrix.2). this layer comprises five-senses experiencing.The ACT Matrix perhaps explore doing it between now and next week when thoughts and feelings of despair show up and entice you to bite. The inner experiencing layer allows clients to discriminate between bodily sensations and thoughts and images and can help them contact how it feels to have a particular mental experience. FIVE-SENSES EXPERIENCING AWAY AWAY MOVES TOWARD MOVES WHAT I DON’T WANT TO THINK OR FEEL WHO OR WHAT IS IMPORTANT TO ME MENTAL EXPERIENCING INNER EXPERIENCING TOWARD POTENTIALLY VALUED LIFE DOMAINS INTIMATE RELATIONS FAMILY PARENTING FRIENDSHIP SOCIAL RELATIONSHIPS LEISURE WORK TRAINING/LEARNING COMMUNITY SPIRITUALITY SELF-CARE/HEALTH Figure 4. some clients are initially unable to respond. Some locate all sensations in their head.2. It may look like a phobia of inner experience or an inability to name inner experience. and in the lower part it extends beyond mental experiencing to inner experiencing. Inner experiencing points to how having a particular thought or image feels and where in the body it shows up. 68 . Many such clients suffer from an unstable sense of self and may find contact with their bodily experience threatening. That’s what we really try to move away from. Therapist: Where does this go in your matrix? Client: Bottom left. I just get really mad and I despair. that’s stuff you don’t want. Often that’s the biggie. But is it mental—the thoughts or images themselves—or is it also what it feels like to have them in that moment? Client: It’s both I guess. particularly values clarification. Values Values work in ACT. values work gets pushed back toward the end of therapy. training their attention toward five-senses experiencing can help them gradually open up to their bodily sensations. clients can progressively learn to recognize their feelings and develop a more stable sense of self.) Therapist: Yes. The matrix can help simplify values work by recasting it in terms of discriminating between 69 . In our clinical practice. Client: Yep. and I feel this weight there (pointing to his upper belly). Not so much the words or images. So it goes there? (Points to inner experiencing. In this manner. Traditionally. but how they make us feel inside. That’s how we become like Spiky. can become a verbal minefield. Therapist: Yes. I can’t stand it! Therapist: So that’s your inner experience of feeling sad and angry? Client: Yes. Me. that’s what I do. It’s how they make me feel.You. and the Matrix: A Guide to Relationship-Oriented ACT Therapist: So when this thought that nothing will work shows up. when progress with defusion and acceptance make it less likely that client and therapist will get stuck. by contracting our inner experience so as to not feel it. you become sad and angry. for sure. What’s that like? Client: I don’t know. It grips me here (pointing at his chest). we’ve also noticed that when clients have difficulty or refuse to contact inner experience. ) It’s a little hard to open up to it. 70 . But would you like to be able to open up to other people’s care and affection? Client: Well. this can be evoked by the therapeutic relationship itself. Here too. what do you notice? Client: Fear. Therapist: And what would you like to be able to do? Client: I wish I could be warmer. Using the word “important” rather than “values” can protect both client and clinician from falling into wordy confusion. We’ve seen how receiving other people’s care is difficult for you. and also a warm feeling in my chest. A question as deceptively simple as “What would the person you want to be do in this situation?” can lead to the immediate derivation of valued action. Therapist: I noticed that when I told you I cared about you and was wondering how you had been doing over the week. the therapeutic relationship provides a privileged context for in- the- moment derivation and engagement in moves toward what’s important (CRB2).The ACT Matrix toward moves and away moves. allowing values to take center stage from the get-go. Therapist: And when you do. not so distant. you changed the subject. but through in-the-moment embodiment of his relational values. In that exchange. Client: It makes me feel uncomfortable when you say that you care about me. Therapist: I appreciate you sharing what you genuinely feel. As the most important values often involve relationships. how about now? Can you open up to the fact that I care about you and wonder how you’re doing during the week? Client: That’s nice… (Pauses and chuckles. Therapist: Okay. my ex-wife complained I always made jokes when she tried to say she loved me. the client is moving toward his relational value of opening up to other people’s affection—not through elaborate values clarification. to imagine being teleported to a difficult situation and noticing their matrix in that situation. it may also be a move toward resting at the end of an intense week. Me. Another effective way to train flexible perspective taking is inviting clients as they are here and now. and the Matrix: A Guide to Relationship-Oriented ACT Perspective Taking The matrix trains flexible perspective-taking skills. Framed as a move toward self-care. Noticing the Toward in Away Moves At first. We do this work by inviting clients to adopt the matrix perspective (discussed in chapter 2). In the therapeutic relationship. to the self-care dimension within many away moves. Because few behaviors are purely away or toward moves. Special Clinical Skills This section briefly outlines a few clinical skills that we’ve found useful in our clinical and training work. as they will be there and then. this may lead 71 . a client may see not accepting an invitation to Friday night drinks as an away move. Being aware of what shows up in the situation. and their minds will beat them up for it. Once the skill has been trained in the therapeutic relationship.You. we can point. Clinicians can help clients notice toward moves within away moves. The therapist can conclude the exchange by asking clients how probable they think it is that they. In our example. could tell themselves. we invite clients to take our perspective and describe what they would experience if they were the therapist and we were the client. in contact with their matrix. will be able to go and assist themselves there and then. is there something they. the behavior is thus pulled to the right and starts acquiring appetitive functions that make it more probable that clients will start choosing additional behaviors on the right. for example. some clients will see everything they do as away moves. as they are here and now. gently returning attention to what’s important and choosing action. However. it can generalize to the client taking the perspective of significant others by taking the perspective of their matrices. For example. as they are here and now. that could help? This dialogue can lead to an exploration of self-validation strategies. 72 . Candidly admitting what the away move was and inviting the client to share how this move impacted him can get therapy moving again and engage the client in a conversation aimed at defining more effective therapist behavior. in addition to disclosing their inner experience. and especially in interpersonal relationships. A clinician could thus choose to disclose that she’s feeling anxious because she’s awaiting news of the outcome of an operation a sick relative is undergoing. Matrix Spotting An effective way to promote generalization of behavior practiced in session is inviting clients to see if they can spot the matrix in their life outside of sessions. She could also choose to disclose that when the client rejects her praise. receiving. and that it will start popping up in many life situations. Not infrequently. We sometimes tell clients that now that they’ve started looking through the matrix. she notices feeling pushed away. they won’t be able to unsee it no matter how hard they try. therapists can share what their hooks are and what an away or toward move could be in the situation.The ACT Matrix to a broader repertoire of self-care moves. Clinician Self-Disclosure Through the matrix. therapy gets stuck after therapists engage in away moves. clinicians may choose to self-disclose if this is done in the interest of helping clients better identify the interpersonal functions of their own behavior or as a way to model processes and let clients contact their shared humanity with the therapist. This conversation can be part of a joint case conceptualization (see chapter 11) and also gives the therapist a chance to model engaging in a functional exchange around getting. Sharing Therapist Toward and Away Moves When feeling stuck. which could now extend to exercising more regularly or more readily accepting invitations. and acting upon interpersonal feedback. You, Me, and the Matrix: A Guide to Relationship-Oriented ACT Homework When using the matrix, homework isn’t called homework; instead, it’s home practice. It’s simply about noticing, not about having to do anything in particular. In addition to ensuring client compliance with “homework” (as long as they commit to noticing), it’s also an excellent way of working through pliance and counterpliance issues. Couples Work Space precludes a thorough discussion of how to use the matrix for couples work. However, many of the strategies outlined above can be used with couples; therefore, we will briefly sketch how they can be adapted to couples work. Setting Up As we introduce the matrix, we get each partner to fill out an individual matrix, while we often fill in their matrix as a couple. Each partner writes his or her own values, suffering, and away and toward moves as they’re identified, and those they have in common are recorded on the couple’s matrix. (See also the “Second Loop Around the Matrix,” in chapter 14, for a discussion of shared matrix work.) Combining Personal and Couple Values The goal of therapy can then be set as combining what’s important to each partner into what’s important to both as a couple, and supporting both partners in their ability to choose to engage in both individual and couple-related toward moves even in the presence of unwanted inner experience. An effective way to tease out relational values is the Cereal Box metaphor. Therapist: Imagine you’re in the shop of all possible relationships. They’re lined up on shelves like so many cereal boxes. You can read the ingredients on the boxes and pick your ideal relationship. There are two columns for the 73 The ACT Matrix ingredients: one for what each person brings to the relationship—what each would do. Which ingredients would you choose? Noticing Workable and Unworkable Behaviors The therapist gently invites each partner to identify his or her toward and away moves, taking care to encourage each partner to link to both what’s important and what he or she doesn’t want to think or feel, and then asking the other partner how that behavior works for him or her. Guided by the therapist, both partners can then discuss more effective behaviors that would better take into account workability, and the impact of their behaviors on each other. Perspective Taking and Couple Communication The matrix is well suited to helping partners become more aware of each other’s perspective. The Fence metaphor can help. Therapist: When we discuss the content of our matrices, it’s easy to lose perspective and waste time looking for the “truth.” When we’re in conflict, it’s a bit as if there was a fence dividing two gardens. We can lose precious time arguing about the color of the fence: “It’s green!” “No, it’s blue!” Only when we look from inside the other person’s matrix can we see that it looks different depending on which side of the fence we’re standing on. When each partner describes his or her own inner experience in terms of the matrix, this also has a distancing quality for both partners that makes it easier to create space for the other partner’s perspective. Both partners can then be invited to describe how things might appear from the perspective of the other person’s matrix. 74 You, Me, and the Matrix: A Guide to Relationship-Oriented ACT Couples Home Practice The matrix provides an effective framework for setting couples’ home practice. Partners are invited to see their relationship as a garden in which they can choose what they tend to. In session they can start practicing ways of watering what they want to see grow, and then between sessions they can explore watering these seeds. Here again, the main task is noticing when the matrix shows up in each partner’s experience, and whether they choose to move away from discomfort or toward what’s important to them in the relationship. Conclusion In this chapter, we illustrated how the matrix could be used to integrate relationship-centered strategies from FAP into ACT-based interventions, and as a tool in couples work. We believe that the matrix is ideally suited to integrating exercises and procedures from other approaches with ACT-based interventions, as long as this is done in the service of moving toward what’s important (i.e., under appetitive control, rather than aversive control of moving away from discomfort). We hope this chapter has given you a taste for using the matrix as a flexible cue for therapists engaged in relationship-focused work, helping clients move toward the life and relationships they want. References Boulanger, J. L., Hayes, S. C., & Pistorello, J. (2010). Experiential avoidance as a functional contextual concept. In A. M. Kring & D. M. Sloan (Eds.), Emotion regulation and psychopathology: A transdiagnostic approach to etiology and treatment (pp. 107–134). New York: Guilford. Kohlenberg, R. J., & Tsai, M. (1991). Functional analytic psychotherapy: Creating intense and curative therapeutic relationships. New York: Springer. Lara, M. E., Leader, J., & Klein, D. N. (1997). The association between social support and course of depression: Is it confounded with personality? Journal of Abnormal Psychology, 106(3), 478–482. 75 The ACT Matrix Peirce, R. S., Frone, M. R., Russell, M., Cooper, M. L., & Mudar, P. (2000). A longitudinal model of social contact, social support, depression, and alcohol use. Health Psychology, 19(1), 28–38. Schoendorff, B., Grand, J., & Bolduc, M. F. (2011). La thérapie d’acceptation et d’engagement: Guide clinique. Brussels: DeBoeck. Teo, A. R., Choi, H., & Valenstein, M. (2013). Social relationships and depression: Ten-year follow-up from a nationally representative study. PLoS ONE, 8(4): e62396. Tsai, M., Kohlenberg, R. J., Kanter, J. W., Holman, G., & Loudon, M. P. (2012). Functional analytic psychotherapy: Distinctive features. Hove, Sussex, UK: Routledge. Tsai, M., Kohlenberg, R. J., Kanter, J. W., Kohlenberg, B., Follette, W. C., & Callaghan, G. M. (Eds.). (2009). A guide to functional analytic psychotherapy: Awareness, courage, love, and behaviorism. New York: Springer. Tsai, M., Kohlenberg, R. J., Kanter, J. W., & Waltz, J. (2009). Therapeutic technique: The five rules. In M. Tsai, R. J. Kohlenberg, J. W. Kanter, B. Kohlenberg, W. C. Follette, & G. M. Callaghan (Eds.), A guide to functional analytic psychotherapy: Awareness, courage, love, and behaviorism (pp. 61– 102). New York: Springer. Vittengl, J. R., Clark, L. A., & Jarrett, R. B. (2004). Improvement in social- interpersonal functioning after cognitive therapy for recurrent depression. Psychological Medicine, 34(4), 643–658. Vittengl, J. R., Clark, L. A., & Jarrett, R. B. (2009). Deterioration in psychosocial functioning predicts relapse/recurrence after cognitive therapy for depression. Journal of Affective Disorders, 112(1–3), 135–143. Whisman, M. A., Sheldon, C. T., & Goering, P. (2000). Psychiatric disorders and dissatisfaction with social relationships: Does type of relationship matter? Journal of Abnormal Psychology, 109(4), 803– 808. Wilson, K. G., & Murrell, A. R. (2004). Values work in acceptance and commitment therapy: Setting a course for behavioral treatment. In S. C. Hayes, V. M. Follette, & M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive- behavioral tradition (pp. 120– 151). New York: Guilford. 76 CH A P T ER 5 Rolling Out the Matrix, Rolling Back Addiction Mark Webster This chapter is mainly a story about the development of a systematic group approach to addiction treatment based on the matrix. The matrix was coinvented during the development of a new approach to addiction treatment in the city of Portsmouth, UK. The process took place over five years, starting in 2007, during which time the addiction services in Portsmouth evolved to become firmly based on the matrix model. What follows is an anecdotal account of the journey we undertook and the cultural change in addiction services provided by the city. At this point, I need to acknowledge the vision of the commissioners who were willing to support the groundbreaking development of a new approach to treatment. I’d also like to take this opportunity to thank the many workers and clients who contributed to the development of the model and the services in Portsmouth. You are too many to name, and I am grateful for all your contributions. What Is Addiction? The term “addiction” is increasingly applied to widely different situations, ranging from substance misuse to gambling or sex to shopping and even to ice cream consumption. What this tells us is that addiction is not However. It can be taken even further to describe engaging in a variety of behaviors compulsively. Typically. There is extensive comorbidity with traditional mental health conditions and overlap with serious mental illness. I am going to limit the use of the term “addiction” to describe typical behaviors that are involved in maintaining a strong physical dependency on a chemical substance. It is a kaleidoscope. and such addictions are also addressed here. especially as regarded criminal activity. such as the benzodiazepine family. In 1998 a specialized regional health authority was set up within the National Health Service to coordinate the overall approach to addiction. we need to look at addiction more as a category of disorders that can have widely ranging differences in presentation and underlying cause. substance dependency in the UK more often involves legal substances. (I will leave caffeine out of the discussion!) As mentioned. the term “addiction” is often applied more widely to describe behavior that does not involve ingesting a mood-altering substance. nicotine. Since this is not a chapter on addictions per se. Therefore. such as shopping or spending. as in the label addictive society. often referred to as dual diagnosis. for instance gambling or sex. and even to describe our Western culture. 78 . and a principle- based model seems the only realistic approach. including alcohol. The Context of Addiction Treatment in the UK At this time. this involves substances that are illegal in the UK at this time. The matrix will work equally well with these “compulsive” addictions.The ACT Matrix a single condition that can be defined in the way that a disorder like depression might be. and amphetamines. with services provided free of charge at the point of delivery under the National Health Service ethos. which was becoming a more widely recognized social problem. there is a model of treatment provision in the UK based around specialized treatment facilities purchased locally. cocaine. such as opiates. and prescription drugs. as it does not require the focus on physical dependence that is so heavily emphasized in the treatment of substance misuse. Rolling Out the Matrix, Rolling Back Addiction Access to treatment operates under a system of referral whereby the client receives a comprehensive assessment from a specialist in substance misuse and a treatment plan is drawn up. The client then attends a specialized treatment center, usually some form of community drug team, where another assessment takes place that is more specific to the intervention. These teams are usually centralized, and waiting times can vary. Treatment itself has mainly focused on prescribing the heroin substitute methadone, and more recently buprenorphine, both of which work on opiate receptors. It has been mainly a harm-reduction strategy in which people are encouraged to taper off the methadone and undergo detoxification or attend residential care. Once people are substance-free, their treatment is regarded as complete and they are discharged with very little aftercare. Previously, the main community treatments available have been through 12-step fellowships, such as Narcotics Anonymous (NA) and Alcoholics Anonymous (AA). Additionally, there have been community day programs or centers that can be freely accessed, as well as counseling. Level and quality of services provided varies widely across different regions. Initially, treatment was focused on drug problems, with alcohol treatment being more systematically addressed only since 2008. The two streams aren’t yet fully integrated across the country, contributing to a system of treatment that is fragmented and made up of multiple modalities. Accessing treatment can be a minefield for the client. Client Group People presenting to the system have usually reached a fairly desperate situation in life, often referred to as rock bottom. This is a specific incident or moment that shocks people into action, such as a hospital admission, or having children removed by social services, or loss of a job. Circumstances vary widely, and for many people these events just fuel further substance use. For each individual, the rock bottom is personal and comes after many, many years of sliding into an increasingly worse condition. Clearly, such people need a model of treatment that is simple and well organized. What this means when considering a treatment model is that the system is usually dealing with people whose physical and mental health 79 The ACT Matrix are at an extremely low ebb. In most cases, their lives are chaotic and filled with all sorts of difficult problems, and their support systems have disappeared. People who present for help usually have a high level of life difficulty and low access to resources. It is a very tough starting point, and we can expect many relapses as people progress through the journey of recovery. This places an emphasis on engagement, and particularly the use of the “Yes, and?” skill (discussed in chapter 1). People who enter treatment are typically feeling unsafe and out of control in daily life, and they also belong to a social group that is heavily stigmatized. For that reason, it is particularly important to create an environment that is safe and interesting for new clients. In fact, clients often report that having a safe place really matters, and that being with a group of similar people is a relief from the stigma experienced elsewhere in the course of their recovery. First Attempts in Portsmouth It was against this background that the initial work in Portsmouth began in an effort to provide an alternative for people who had been through the existing services many times and kept reappearing for treatment. Unfortunately, this type of revolving door phenomenon is an all-too- common problem in addiction treatment. Our task was to help people move on, creating some lasting gains for the services. The initial projects were located in the detoxification unit and the community drug team, which had mainly prescribed methadone and prepared people for detox. Since clients in these locations had usually been through the system many times, most were initially skeptical about attending another group. Often they attended just to comply with the requirements of their treatment plan, so initially they would not put a lot of energy into participating. The format of the new groups required every member to process examples on the matrix. Seeing examples being processed by others allowed new people to identify with common, shared problems, and the focus on values helped them quickly realize how different the matrix model is, leading to greater engagement. 80 Rolling Out the Matrix, Rolling Back Addiction A System Based on Values From the beginning, we were sure that the new intervention needed to be focused on recovery, and that basing the system on the values component of acceptance and commitment therapy could be a way to do that. We understood that it was not enough to get people to stop using drugs and practice relapse prevention. To recover from addiction, they needed to build a life worth living, and values are the perfect basis for that. It was also clear that resources were limited and that financial pressure in the public sector meant any growth in budgets was unlikely. In fact, it was far more likely that budgets would be cut. Therefore, we had to create a financially efficient group model of treatment. Since there was no group model of ACT at the time, we had to innovate. Group Treatment My own background was ten years of experience with dialectical behavior therapy (DBT), which is where my interest in behaviorism started, as well as an interest in ACT fueled by my dissatisfaction with the “symptom-first” approach of DBT. I had already run a few ACT-like groups focused on the traditional six components of the hexaflex, but with limited success. I was ready for something more effective and went over to visit Kevin Polk, at the Togus VA Medical Center in Maine. I brought the iView format, as it was then called, back over to the UK and started using it in groups, but it proved to be confusing for clients. Early on, we understood that the model needed to be simple and visual because clients are in such a state of disarray when they enter the treatment setting. The elements of noticing were there in iView, along with acceptance and defusion, but the tool was not clear enough. We could see that we were on to something—and that it was not yet the finished article. Fortunately, enough clients started engaging with the approach and making strides to recovery that we were able to maintain funding for the project. The Grid When I was at Togus, we improvised a role-play in which the client was visually presented with two choices. This was the first time I had 81 The ACT Matrix clearly observed a client faced with a discrimination task, and I was struck by how effective it was. I remember christening this “the hingeaflex.” When I got back to the UK, we started using it in supervision under the name “the grid,” which looked exactly as the matrix does today, but with different labels. Kevin Polk and I were Skyping regularly during this phase, and somehow the diagram evolved to use the discriminations that exist today. Kevin called his diagram the matrix, and I called mine the grid. Later we settled on one name. Once I started using the grid with clients, there was a visible lift in their levels of engagement and progress. People were responding to a values-based approach, and we were clearly on to something. It was so popular that we started producing a number of graduates who needed more of an aftercare approach. Happily, we were able to conduct a group in a community center, and it became the template for our current group format. Group Format By this point, we were using the standard matrix diagram with the two discrimination lines and four quadrants and getting clients to sort their experiences onto the diagram. Next, we built a structure for the group that allowed us to focus more clearly on some of the individual components of ACT, such as values and acceptance. A structure for the groups emerged in which we began with mindfulness, then sorted examples on the matrix, and then did an activity around one of the components. We still use this standard structure today, though we leave out formal mindfulness with drop-in groups. We use the standard homework statement at the end, inviting people to either notice where they are on the matrix or not to bother with the homework, as people often don’t like homework and it’s all the same to us. These are all written up in the manual 60 Ways to Use the Matrix, which is unpublished but available from me by e-mail. (Please send requests to
[email protected].) Group Guidelines As the approach gained popularity, we started to diversify the locations where we ran groups, so we needed to have a clear set of guidelines for groups that were independent of the setting. These guidelines were 82 Rolling Out the Matrix, Rolling Back Addiction developed by the service users using a toward and away approach until we arrived at a set that seemed to work (which is included in the manual 60 Ways to Use the Matrix). Decentralized Groups The number of groups we were running continued to grow, and we were running more and more groups in the community. One of the groups we started was in the local general hospital working in conjunction with the Alcohol Specialist Nurse Service, only the second such service in the UK at the time. We set up an integrated psychosocial interventions service offered in the ward—the first program of its kind in the UK. This was another pivotal moment. Although it had been a chance decision to set up the groups in the hospital, we immediately started to notice how popular this was with patients. When we asked them about their experience, they tended to give similar responses. They liked coming to the hospital because it was perceived as a normal environment, allowing them to avoid the stigma associated with specialized addiction centers. Furthermore, many patients with alcohol problems preferred not to be treated in the same groups as people with drug problems. We were also able to bypass the lengthy referral system so people could self-refer after a relapse. We were surprised by how successful this was, as we had all worked in addiction services for a long time, and this didn’t conform to the usual pattern. Excluded Clients Because the first ward-based program was a pilot project, it underwent an external audit. When we looked at the results, we had 100 percent satisfaction from those attending the matrix groups. This got us thinking about the basic assumptions in the existing model of provision. Another group we were running, in a community center, had also started attracting people who were in recovery but not attending specialized services. They were in differing stages of recovery and did not want to be associating with people who were still involved in using. We realized that there was a large group of people who wanted recovery-based 83 The few groups that didn’t succeed were closed down. there is so much variety in clients with addiction that just about anything could be an obstacle or barrier. This meant working with other agencies and running groups on their premises with a direct referral pathway. and tried again. and for those. and like the hospital groups they were well attended and valued. We wanted to see if we could expand the service and include clients who wanted the recovery aspect of treatment rather than the drug or alcohol aspect. In each instance we met with the local managers and staff to identify the needs of the client group and set up times for groups to be run. The first agencies we looked at were Probation. and we decided to base groups in community locations. Some were from 12- step fellowships and some were not. there seemed to be a second stage in which obstacles and barriers to progress started to show up. 84 . Mental Health. Numbers of people attending the groups continued to grow.The ACT Matrix treatment but did not want to be involved in traditional services that focus on the substance rather than on the person. people would present with the consequences of their addiction being the main factor. Generally. Stages and Barriers We found that participants naturally progressed through stages. Early treatment involved learning to be in a group (maybe for the first time). As stated earlier. these groups flourished. did a toward and away analysis. understanding the values-based approach of the model. we went back to the drawing board. and there was a demand for different levels of groups so the work could be progressively more challenging. Once people had engaged with the work and settled in. In the first stage. and starting to engage in some early progress toward what is important. and Housing. and most people had several. Social Services. Diversified Locations The success of the hospital program allowed us to expand the alcohol service. Primary Care. but then their engagement would taper off. People coming into the program had been admitted to the hospital with serious health problems as a result of their alcohol use. which emerge as treatment progresses The difficulties of change. as people develop a life worth living 85 . so did the contingencies for engaging in treatment. as soon as people’s symptoms went away. Treatment as Aversive Control In the ward-based program. This is one of the areas that we are still working to improve. in fact. or stomach. Rolling Back Addiction Additionally. going back to college). Typically. moving away from the symptoms of bad health. We have noticed a tendency for people to become comfortable in their home group and not move on to the higher levels. This allowed us to better understand the extent to which aversive control dominates in this client group. leaving no appetitive control.Rolling Out the Matrix. which tapers off after engagement in treatment Resumption of negative emotions suppressed by drug or alcohol use. or entering unfamiliar environments (for example. heart. We noticed that people would come into the program and work hard in the early days. developing new behavior. You might even say they are addicted to it. these were problems with the liver. We realized that there are three main aversive control hurdles that have to be overcome in the journey of recovery: Movement away from the consequences of using. we figured out what some of the relapse patterns were about. Therefore. which could lead to an expensive stay in intensive care. creating another set of difficulties. When we analyzed this. the intermediate-level groups were usually held in a different location than the one in which the home group met. where people first presented. Our hypothesis is that a lot of the early issues that bring people to treatment are moves away from the consequences of their addiction. we realized that moving toward health was. So as the aversive control of engaging in treatment started to fade. It became clear to us why people were not progressing into stage-two and then stage-three work. whereas in fact we were not providing the necessary tools to help people overcome these weighty obstacles. or criminal justice consequences in probation. once people had engaged in treatment and reduced the frequency of their initial presenting behaviors. feelings. social services. so the dominance of aversive control is perpetuated by the institutional culture of these agencies and the government bodies that fund them. which is about reintegrating into the community.The ACT Matrix This helped explain the high rates of relapse and low rates of success in the harm-reduction approach. going to new places. a new set of aversive stimuli that would drive people back into addiction emerged. And. 86 . This corresponded with another observation: that people typically stay in their treatment settings and do not move on and reintegrate into the community. However.” Those who stayed with treatment. they were left with the same unwanted thoughts. standard mental health outcomes are defined in a similar fashion. without any appetitive element. People would instinctively want to move away from that and stay in the home group. Government outcomes normally represent a successful use of aversive control. Then the services would typically be withdrawn as if treatment were a success. hospitals. For example. family consequences in social services. and physical sensations that their addiction had helped suppress. What we observed in stage one is that people would participate in treatment and successfully escape the consequences of whatever got them to engage with services in the first place. were then faced with the third set of obstacles to recovery: the challenges of meeting new people. and trying new things in a community that stigmatizes addiction. and the criminal justice system define good outcomes by the absence of those very consequences. Usually. a result of people switching from one form of aversive control to another as treatment progressed. Our analysis is that harm reduction helps people move away from the consequences of their addictions. perhaps because some form of appetitive control had been established. clients were blamed for the failure. No wonder people relapse— it’s a double whammy. I call this the “relapse shuffle. of course. In fact. these might be health consequences in the hospital. which is more comfortable and safe. we developed an unrelenting focus on appetitive control and made sure that all the groups we conducted were training clients to develop new repertoires that were under the control of positive reinforcement. and whether the groups are being run effectively. D—Direction.” We ask people to express their statement as an activity or behavior so it can be used to build new behavioral patterns that are not under aversive control. 87 . An example of an objective that doesn’t pass the test is “not feeling bad. This is the opposite of the corpse test or dead man’s rule. Finding the deepest connections of meaning and purpose in an individual’s life is crucial to cultivating appetitive control. and then we did a second round of introductions in which we asked each client to talk about “what is in your heart right now.Rolling Out the Matrix. Focusing on appetitive control became the truth criterion for the project. We also changed the way in which we worked with positive reinforcement by breaking it down into three parts of a powerful toward statement. Now we are able to monitor our own behavior in terms of toward and away moves in setting up appetitive control contingencies for our clients. which are short-term and disappear when reached. We changed the structure of the groups so that we started with a round of introductions in which clients stated what was important to them.” This allowed us to tap into the most effective streams of appetitive control for each individual and also created a group culture that was more focused. L—Living. whether they are in the correct level of group. we use the idea of directions and the metaphor of a compass to support long-term changes that create stability. Rolling Back Addiction An Unrelenting Focus on What Is Important From this insight. using the acronym WILD: WI—Who or What Is Important. This allowed me to develop a system of measurement that assesses how individuals are progressing in their recovery. which states that any objective that could be achieved by a dead person cannot be a workable therapeutic objective for a living person. Instead of goals. or engaging in a new leisure activity. enrolling in courses. applying for a job. The term “challenges” is very intuitive for group members. Activities We realized that we had to carry the focus on what is important through to group activities. like raising the bar on a high jump a notch at a time. compared to the scales! Challenges We developed challenges as one of the key components of the program because this effectively tells us about the level of aversive control being maintained. Including challenges allows us to monitor each client to ensure that everyone is learning to overcome barriers and obstacles. We now provide many more activities that are focused on developing appetitive control. When we started to apply the system. mental experiencing) and D2 (toward vs. Challenges are set monthly in community programs and weekly or biweekly in residential programs. away) structure of the matrix. each person both develops new behavior under appetitive control and engages in exposure work around the internal aversive stimuli that had previously been generating away behaviors. The challenges are individualized behavioral tasks that require each person to confront a higher level of aversive control than previously. It allows group leaders to make systematic assessments of clients’ progress. The information is then entered into a database that allows client progress through recovery to be charted at a push of a button. and have even created an activities book called Take a Walk on the Wild Side that contains thirty ways to work experientially in groups with the ACT components.The ACT Matrix iGro The Individualized Generic Recovery Outcomes (iGro) is a system of measurement I developed based on the D1 (sensory vs. sorting out money issues. Common challenges involve dealing with difficult interpersonal situations. We 88 . rather than relying on feel or opinion. we discovered that our opinions were not very accurate. Each dimension is based on a simple scale of 1 to 5 scored each time there is contact with a client. Through the systematic application of challenges. as they are in a better position to provide the individual support and encouragement that clients need to overcome their obstacles and barriers. and they use their experience to help people along the road to a better life. we have come to work more closely with people who are in recovery. Clients are invited to select one that represents an area of their life that is difficult. Each then talks about why he or she chose that picture. Rolling Back Addiction also noticed that people did not like talking about their away behaviors. This is then processed in the larger group using the whiteboard. Community In Portsmouth we are fortunate to have a strong 12-step community and now a strong community of people in recovery who operate as a service user group called PUSH (Portsmouth User Self Help) funded by the commissioners. For example. not talking about away behaviors is an away move. From this work emerged a second overall direction for the project: maintaining as high a level of exposure practice as is appropriate. In this way.Rolling Out the Matrix. PUSH members act as “recovery brokers” and receive training and supervision. PUSH members follow the same format of focusing on what is important. Over time. we have increased the level of aversive stimuli in group activities to provide another opportunity for exposure work and progress in facing aversives. Then we ask them to think about and list the aversive stimuli that underpin these behaviors (known as “not wants”) and to think about and list the long-term negative consequences of each. This community (PUSH) is reinforcing to belong to and provides opportunities for others in recovery to safely learn new skills and try new activities. Consequently. all participants talk about their own aversive stimuli. thereby contacting some of the aversive stimuli while talking and engaging in new behavior in the presence of those stimuli. In another activity we use laminated pictures that we spread on the floor. 89 . so we include an activity in which we put clients into small groups and get them to generate lists of away behaviors and think about which ones apply to them. as doing so is also under aversive control due to the high levels of stigma and shame that surround addiction. but they do so in a safe environment that normalizes much of the experience. Most of the activities follow a similar pattern. we have not only been able to locate services where clients are but have also created an integrated pathway that is holistic and addresses the full range of client needs. we can also deliver treatment through nonspecialist workers. using the “Yes. we can reach many more people and reach them much sooner. the frontline workers in these agencies have had to refer to specialized substance misuse services. Probation. Through the matrix. This is another area where we have innovated and made a considerable change in the culture. Using the matrix. Most people referred never make it to those programs. Training is delivered through workshops and observing a more experienced leader. in addition to delivering treatment away from specialized addiction centers. up until now. and?” skill. In fact. how to deal with the substance misuse element of the situation. Social Services. we’ve needed to train more people to deliver the groups. This allowed us to make another paradigm shift in the way we approach treatment. before their lives get so bad that they need a specialized service. Although it is an extremely obvious statement. which is a relationship-building tool. such as Housing. the model is so simple and straightforward that it can be taught to almost anyone. I created a system of training people that involves learning three main competencies: sorting to appetitive control. and understanding how to run activities and conduct exposure work. All feedback is against the three competency areas and the standard group structure. Behavior change is no longer just the province of specialists. This means we can teach people in many agencies. addiction is a condition that affects all corners of society. Task Shifting The matrix has allowed the development of a completely new paradigm in addiction treatment. People with addictions turn up in all agencies and.The ACT Matrix Training As the system has grown. we can transfer skills out to workers in all agencies and equip them to deal with not only addiction problems but also other behavior change problems. Through this 90 . and. by shifting this task out into the community. We have been able to train all manner of nonspecialist workers in this way. and Education. It can also be delivered by anyone who has a sincere wish to help others. The next phase of the work is to reach the point where the whole system develops appetitive control at every opportunity. Conclusion While this has been the story of the journey toward a new model of addiction treatment in Portsmouth. but it will take at least another five years to change the wider culture. The system is becoming a functional contextual one. These standards are behavioral and based on the idea of working on who or what is important for the client.Rolling Out the Matrix. we are now seeing changing attitudes toward substance misuse and treatment across many agencies in the city. 91 . and service users to create a set of standards for practice based on a recovery model. we have worked with the commissioners. it is also a story of how the matrix can be used to broaden the reach of the functional contextual approach to the places where it is needed. The model is simple and universal. It can be taken outside the walls of traditional specialized centers and made available in a more timely fashion where and when it is needed. Rolling Back Addiction work. service providers. and affects the whole of society. so it is suitable for all people. These are all essential in addiction because it is a condition that knows no limits. and is monitored. whether they present in crisis or are simply struggling with life. Standards Over the past two years. . There is an excellent book-length description of ACT in chronic pain treatment (Dahl. Acceptance and commitment therapy and its underlying assumptions provide a useful orientation for assessment and treatment of complex chronic pain. . & Silman. & Wilson. stenosis. chronic pain frequently co-occurs with mental health concerns at rates of 10 to 50 percent (Asmundson. In this chapter. Research suggests that anywhere from 20 to 70 percent of patients in primary care settings present for chronic pain (McBeth.. or post-laminectomy syndrome. Complicating the diagnosis and treatment process. I’ll outline how the matrix can be used to assess and treat patients with chronic pain in the hopes of improving their quality of life. many clients with chronic pain get shuffled around from provider to provider without a consistent treatment plan. longer than three months—the medical community may determine the pain to be chronic and diagnose chronic pain syndromes like fibromyalgia. Hunt. & Norton. Gibson. 2001). 2011. Turk. When physical pain complaints last longer than expected—say. Luciano. 2011). Morasco. Wetherell et al. 2012. Corson. 1999. to name a few. “Chronic pain” is a broad term that can encompass a wide variety of medical diagnoses. Norton. 2005). Macfarlane. & Dobscha.CH A P T ER 6 The Pain Matrix Amanda Adcock Vander Lugt Human beings experience many types of pain in the course of a lifetime. Because of the associated complexities. back pain. The ACT Matrix ACT Assessment and Case Conceptualization A thorough ACT-based assessment will be grounded in some basic assumptions of case conceptualization. Assessment starts with a brief description of the format of the session. briefly describe the premise of ACT. Without debating this point. and treatment processes. it’s important to lead clients toward exploring their own experiences with pain. this idea can be tricky to get across. The first question I ask clients is “What is important to you?” With this I express to clients that I view them as whole people with things they care about out in the world. With chronic pain. and complete written assessment measures. I point out that pain and suffering are only a part of their whole life and use follow-up questions to gain a fuller sense of what drives them and who is central to their life. it is understandable that they would feel this way. A second basic underlying assumption of ACT case conceptualization is that either there is a solution to the problem at hand or there isn’t. The therapist communicates to clients that they will be in charge of deciding if they will continue with treatment beyond the first assessment appointment. Many people living with chronic pain may feel that this is impossible or that nothing can be done. even if they have been referred by another provider. Within the first few moments with a new client. Many people believe that having pain means something is wrong. I explain that the work I do with people with chronic pain conditions aims to help them find ways to improve their quality of life. case conceptualization. I inform clients that I’ll ask questions to better understand their treatment goals. being careful to include information from their medical 94 . ACT is inherently client centered. relying on the client to both set the course for treatment and determine if the treatment is necessary. then assess the available options. Valued living drives the assessment. Given the myriad of doctors they have likely visited up to this point. Don’t let this discourage you or the client. First and foremost is the belief that all people have the capacity to choose things that are important to them. and then I ask if the client is interested in improving his or her overall quality of life. These first assessment questions set the tone for the entire treatment. The guiding assessment question is “In a situation where pain is inevitable. The matrix for chronic pain. we may need to approach the pain from a different perspective. It’s as useful in session as it is to measure treatment progress. Objective assessment tools can be useful both for setting the course of treatment and for indicating changes as a result of treatment. we can get to work. The matrix places the person in the center. The Chronic Pain Acceptance 95 . where pain is a part—and only a part—of a full life.The Pain Matrix treatment providers. & Roberts. External Experiencing (Five Senses) Values: Family Intimate Relationships Parenting Away Toward Friends Education Work Recreation Spirituality Citizenship Health Internal Experiencing (Inside the Skin) Figure 6. Kitchens. The perspective I suggest can be represented using a version of the matrix with some slight variations specific to this population (see figure 6. If there is no medical solution. 2010) is a measure of valued living. Wilson. what would you choose to live for?” Once we answer that question.1.1). The idea that the pain may have a biological cause is only partially relevant to this conversation. The driving factor should be that either there is a solution to the current pain problem—such as surgery or any other treatment that can resolve it—or there isn’t. Sandoz. The Valued Living Questionnaire (VLQ. Even if clients are hesitant. exploration or flexibility is an important seed to sow early. Informed consent can be accomplished by asking clients how people learn things to gauge their understanding of the matter. In order to further the process. Other measures of ACT-relevant constructs that may be useful include the Acceptance and Action Questionnaire–2 (AAQ-2. experiences.. 2004) assesses the client’s current relationship to pain. Sorjonen. Many things are learned very effectively through instructions and how-to descriptions. and then explaining that we learn either through doing or through being told. I ask. but some are not. to become contextual behavioral scientists. people eventually get to the concept of 96 . In other words. Bond et al. 2010). Vowles. 2011) and the Psychological Inflexibility in Pain Scale (PIPS. McCracken. & Eccleston. and bodies. A key component of the assessment is determining whether clients are willing to explore the idea that there are ways to move forward with life other than attempting to control pain. Another thing humans appreciate is the idea that they are the experts on their own lives. & Olsson.The ACT Matrix Questionnaire (CPAQ. “Can you tell me how to ride a bike?” In explaining. in order to move forward with presenting and working with the matrix. People like to be heard and usually respond more rapidly to the process of becoming contextual behavioral scientists—which is what doing ACT effectively leads to—if they feel that the person giving them the information cares about them and believes that they can experience improved quality of life. And carefully listening to what people say during the assessment process is essential. we learn through our own direct experience or indirectly through rules and words about how the world works. ACT for Chronic Pain Using the Matrix Setting up the matrix is important in preparing people to hear the perspective that it offers and adopt it. A basic willingness on the part of the client to listen and attempt to apply the model to life is key and can be gradually shaped over time. This can be used as a way to invite them to let their experiences be the guide to what works—in other words. Wicksell. clients need to grasp a few things and consent to treatment. Lekander. Here. Matrix Overview Please refer to figure 6. and normalizes it. and sensations. When this happens.” is the center of the model. This slowing down is both useful and unusual. you have to experience it to know. This is our treatment contract: we will continue to gain perspective for the purpose of moving toward a valued life. “What is balance?” Of course. Here it may be useful to discuss everything that can occur inside the skin. which represents the two ways that humans experience things. This is all to help you develop psychological flexibility so you can better engage with things you care about. Then I ask. much like for balance. I invite people to experience an object and describe their experience of it with each of their five senses. I use a series of questions to create a context that makes this distinction come alive. I will usually write “Me” in a circle at the center and then ask. thoughts. of behavior.” If the patient says yes to the contract. or “me. we will try exercises designed to create an experience. we simply will not have the words to adequately describe the experience. The self. Then I ask them to put the object aside and experience it through the other way of experiencing: internal.1 for the perspective described in the rest of this chapter. or purposes. Then I outline the ACT approach: “At times in our work. we move into exploring the new perspective.The Pain Matrix balance. feelings. The horizontal line can be described as the skin barrier. because human beings’ perspective has them at the center of their own universe. I begin with a trick question: “Have you ever experienced pain?” This both highlights clients’ experience. including pain. At the top is the way that people take in information about the world around them: through the five senses. with things that happen inside the skin falling below the line and things that happen outside the skin falling above the line because they are experienced through the five senses. represented at the bottom of the vertical line. The horizontal axis is the behavior line. as all human beings experience pain. “How do you experience or take in information about the world?” This begins the exploration of the vertical axis. Through a mindfulness-based exercise. Pain 97 . such as memories. People usually report that they haven’t paid attention to their direct experience in that way in a long time. It represents the two major functions. I clarify by asking about the present moment. just showing clients this model is helpful enough to allow them to make a significant start in moving toward a valued life. Sometimes it may be helpful to ask. I prefer it to individual therapy.The ACT Matrix gets placed in the lower left quadrant of the matrix. highlighting each piece of the model becomes necessary. The purpose of the model and use of the diagram is to help create perspective on where the client is placing attention and what is motivating behavior in the moment. because it’s inside the skin. but often. loving. and kind process. This is in keeping with the traditional ACT question “What are you willing to do and experience in this moment to move toward the things that are important to you?” Walking Around the Matrix to Create Psychological Flexibility The rest of this chapter is focused on the use of the matrix in a group format because I’ve found that having multiple people learning the process together is an awesome. but these are just rough guidelines. The bulk of the treatment can be mapped directly onto the two lines and the circle at the center. If a client is particularly inflexible or focused on removal of pain as the goal of treatment. Sometimes. I’ve indicated session numbers in which various concepts are typically covered. The next question really begins the discussion of the behavior line: “Have you ever done anything to move away from something uncomfortable inside your skin. to be used flexibly depending on the clients and the context. but any of these pieces can be done in individual sessions with a little creativity or a mindfulness exercise. inspiring. like pain?” If this question is unclear. “Are you doing that now?” We then contact the moving toward side through similar questions. “Who or what is important to you?” and “Have you ever done anything to move toward something or someone important to you?” The key distinction is the difference between moving toward something that’s important to the individual and moving away from things inside the skin that are uncomfortable. 98 . for example. more is needed. I invite them to list the problems they suffer in the bottom left quadrant and the solutions they’ve tried in the upper left quadrant. the goal is to uncover the unworkable change agenda by bringing attention to the pain story. and I tell them that. when it works) are temporary in that they don’t resolve the underlying problem. the location of the pain. Therapist: Okay. In groups. but usually they fall into the category of short-term solutions to the pain problem. They can then map out a real-life example on their individual matrices. I ask for an example of pain showing up inside the skin.The Pain Matrix Creative Hopelessness In the first group session. I let clients know that their experience is what will be the guide. In the first group session. Therapist: How long does that work? These solutions may work for a few minutes or hours. First. What do you do? What happens next? Client: I go to the doctor. During the initial assessment. as illustrated in this dialogue. possibly daily. right? Client: Yes. so you go to the doctor to find out what’s causing the pain or to do something about it. clients describe their pain problems. Sometimes there’s an answer or a new medication I can take to help. to manage or control the pain. we look at all of this in a special way. Session 1 is focused on the left side of the matrix diagram. and the many things they try. I want to make it stop. we note how long the pain problem has existed. Who could argue with one hundred years of experience of anything? I sure wouldn’t. There are many things 99 . As clients work with individual matrix worksheets. it isn’t uncommon to find totals of well over one hundred years of experience among all members in dealing and living with pain. Therapist: And how does going to the doctor help? Client: Sometimes it does. The point of this session is to slow down and really look at what is. Therapist: Pain shows up. Most medical answers (aside from surgery. its intensity or severity. the worksheet includes a list of life domains that people often say are important. It’s supposed to—not for the sake of creating depression. Identifying Values Session 2 is focused on the right side of the matrix: values and committed action. and these values are recorded on the right side of the matrix. It looks like a downward spiral and feels like being stuck in a rut. and some that work in the longer term. to help them explore what’s important to them. 1999). Each individual is asked what is important to him or her. In this session. Frequently. If it sometimes goes away. I introduce committed action using the distinction between choosing and deciding in the following riddle: “Three frogs sat on a log. based on the important things in life. in the center. I end the creative hopelessness session with the Man in the Hole metaphor (Hayes et al. This list is by no means exhaustive. solutions. that must then mean there’s an alternative. The matrix is helpful here to help initiate part of the ACT process known as creative hopelessness (Hayes. Strosahl. How many frogs are left on the log?” The answer is three. 1999). This realization can feel heavy and depressing. but nothing that works to remove the pain for life. What might that alternative be? This is the creative part of the hopelessness. because as long as the frog has only decided but not 100 . Because some people have great difficulty stating something important to them. getting thicker and darker in some areas. If there is a whole other side of the model. is not wrapped up in the downward spiral of attempts to control inner experiencing. One decided to jump off.. The middle and right side of the model allow for experiencing that the self. Establishing that values are individual decisions already present inside each person and personal to each person is of utmost importance in this session. but for the purpose of looking at what truly is. The goal of this session is for clients to experience that the process of outlining the problems. it continues to show up. and how they’re linked frequently creates a circle that just keeps going around and around. Values are defined as setting the course for treatment. The process of trying to control things inside the skin leads to feeling hopeless. which illustrates the process of the session and can lead to a thoughtful summary of the experience. it’s just one set of possible domains. & Wilson.The ACT Matrix that alleviate pain in the short term. and by now it’s established that internal experiences can be tricky and get us stuck. (Pause for one second.) Okay. no matter how small. (Pause for one second. This can highlight that decisions are internal. great. Therapist: Great. and I just want you to draw a circle to make a choice. It’s helpful to think about movement toward values as baby steps at first. Next. the better. Choices are decisions empowered by willingness and action—any action. Therapist: On your matrix.) Now draw a circle around a value you’d like to work toward this month. The homework assigned in this session is for clients to identify a value that they can work toward between this session and the next. If people get stuck in their head deciding. I have participants plan an action: a single behavior to move in the direction of that value. that’s all you need to do for this exercise. how quickly this exercise moves can become overwhelming. choosing a behavior that’s attainable to demonstrate the point of valued action. (Pause for one second. draw a circle around a value you’d like to work toward this year.) Now draw a circle around a value you’d like to work toward this week. Does everyone have three circles on their matrix? Inevitably. Returning to the goal of this session—setting a course for treatment—we revisit individual values by preparing homework. Deciding is a mental activity that doesn’t necessarily involve action. Why? It has to do with the difference between choosing and deciding. it hasn’t made a choice. the simpler. It forces them to make a choice or get stuck. Therapist: Can you draw a circle? Client: Yes. A quick exercise using the values recorded on the worksheet can help put values together with choices and decisions by demonstrating that any behavior can establish a valued action or choice. okay? Client: Okay. The value is like a guiding star. I’m going to say something. someone doesn’t make three circles around values on the worksheet. The instructions are simple: making a circle represents making a choice. with the behavior chosen for homework moving clients slightly in 101 .The Pain Matrix jumped. Now imagine putting the first piece up to your lips and taking a bite of that big juicy…lemon! What happened? Did the words on this page perhaps make you salivate a bit? Human minds evolved to turn words into responses so we could learn by indirect means. out for a walk. mindfulness comes to the forefront. delicious-looking fruit. we all would have been eaten before the first book was ever written. A short mindfulness exercise can provide a vivid illustration of the automatic nature of the mind’s functioning. For instance. sometimes when pain shows up. Visualize a piece of fruit. The homework is then simply to do the planned action and notice what happens. It helps us learn things. Has this ever happened to you? Assuming it did. I begin by describing the mind as a tool for humans to use and outline the mind’s job. Sid gets tired of listening to his daughter’s radio and decides to take his dog. just as I would with clients. we’re hooked. Have you ever walked down a hallway and bumped into someone or something? How did it happen? Usually folks say. This session focuses on the lower half of the matrix: things inside the skin and our reactions to them. Fido. In order to communicate mindfulness as conceived in ACT and as relevant to the matrix. See yourself cutting up that ripe. If each of us had to learn from direct experience that lions and bears are dangerous. The purpose of the session is to set up for defusion or mindfulness exercises. When this occurs. He returns home soaked and shivering to find that he accidentally locked 102 . One Saturday. drawing the mind further inward. “I wasn’t paying attention” or “I was lost in my thoughts. thunder breaks out and rain begins to fall. at times this amazing function of the mind can cause problems. The story of Sid and Fido is a great representation of the power of the mind. The Mind In session 3. the mind may say that something can’t be done. The mind is a useful tool that lives inside the skin.” This is the essence of being hooked: attending to internal experiences to the exclusion of external experiences without noticing that this is happening. By the time he gets to the farthest point on his walk. However.The ACT Matrix that direction and serving as a goal along the path. usually quite quickly. I’ll use your own experience to demonstrate. what happened next? Sometimes the thought that we can’t do something hooks our attention. It does many things automatically. Pain hooks us. He can still hear his daughter’s music blaring inside. He pounds on the door and checks every window to no avail. It has to do with how we treat the right side. 2009). Sid or Fido? Willingness Willingness is balancing between the left and right sides of the matrix. Acceptance is like relaxed muscles creating a space inside us that allows us to move forward. at that point we can begin to physically practice a new posture toward hooks and the struggle: acceptance. stomps around. Again. Actually pause here and experience that for a 103 . toward our values. and then we struggle. curls up on the rug. A further way of describing the posture of acceptance is to imagine the difference between experiencing a sunset versus solving a math problem (Wilson & DuFrene. Reactions to pain are often similar: muscles tense automatically. tells his wife what happened when she arrives home. Finally. or are we doing something differently? Session 4 focuses on willingness as a physical posture of acceptance toward internal experiences. Humans get hooked on mental content and experience stress in the absence of the stressor. the radio stops briefly and his daughter hears him banging at the door. Try this sometime if you haven’t. It’s impressive what your body does. walks over to his food dish. Have you ever seen a sunset? How did you respond to it? Think about how your body was as you watched it. and may even tell this story to his friends at work on Monday. What does Sid do? He grumbles to his daughter. This is the difference between animals and humans who are focused on indirect experience. She lets them in. I use a rope to pull a client or a hand to push a client’s hand to demonstrate what happens when something is touching us. This struggling usually lands us back in hopelessness. Are we struggling with internal experiences. and takes a nap. Fido shakes himself off quickly at the door. However. Who would you rather be. To illustrate this physical posture. It’s achieved through practice in noticing the struggle and choosing to do something different. has a snack. when someone pushes against your hand or runs a rope through your hand.The Pain Matrix himself out of the house. I’ll engage your own experience for the purpose of illustrating how to bring these concepts to life for clients. almost without you thinking about it. An automatic response is to tense muscles or push or pull back. with that body posture? Could you do that if it meant being able to have the life you want for yourself? Self-as-Context People can become lost in the patient role. it matters little who wins. I warn clients. When initiating this work. Describing it to clients isn’t helpful. Mindfulness exercises can help clients contact a sense of self that remains stable and consistent through the constant changes in all aspects of their experience—physical. mental. what is needed is the ability to experience this perspective. usually in session 5.The ACT Matrix moment. They are stuck in self-as-content—in defining themselves by the content of their experience. as Dahl and colleagues eloquently describe (2005). the intervention described above may begin the task but still fall short. like the board. and it’s as if it defines them so completely that they can’t imagine a perspective or life beyond it. Describing this perspective. It remains 104 . Their mind has reduced them to their pain and the limitations it imposes. sensory. To pull people from this stuck place. is one of those places where words fail us. The Chessboard metaphor (Hayes et al. throughout all the changes in positions of the pieces and regardless of which side won a particular round. Which of these is more like how you treat pain or other uncomfortable internal experiences? Do you treat those experiences like sunsets or math problems? Could you watch your internal experiences somewhat like a sunset.. Practicing sorting with the matrix is in itself an exercise in self-as- context as clients gradually understand that the perspective from which they observe their matrix remains constant over time and cannot be reduced to their pain or their other experiences. 1999) can be helpful at this stage. known in ACT as self-as- context. They become welded to their pain. and emotional—and through their different roles and ages.” Then we explore the self that experiences things by finding the self that is consistent and has both changed over time and remained the same. or to their behavior or roles. Clients need to adopt a new perspective from which they aren’t reduced to their pain. “Please notice your experience and don’t simply trust everything I say. and to contact the sense of having always been there. Clients are encouraged to see the content of their experience as a set of warring pieces on an infinite chessboard. Then contrast that experience with how you’ve felt while solving a math problem. To the chessboard. memories.The Pain Matrix unchanged. emotions. It brings up some important questions: Who’s driving your bus—you or your internal experiences? What direction are you driving your bus—toward your values or away from pain or discomfort? What passengers show up? How are you treating your passengers? Do you struggle against them? Are you hooked by them? Or can you accept them. it often brings a genuineness to values that feels intensely vital. Putting It All Together: Passengers on the Bus At this point. Contacting a perspective that fosters the experience of remaining the same through whatever changes may come can greatly help people commit to bold moves toward values. Next. with video versions available on YouTube (for example. etc.) show up to stop him or her from moving in the valued direction. The Passengers on the Bus metaphor (Hayes et al. 1999) is an ACT classic. without struggling with any of them and while continuing to drive in the valued direction. bodily sensations. all of the pieces of the ACT model are present and accounted for. Acting out this metaphor in groups can be an effective way to directly experience valued action. we debrief and discuss differences the driver noticed between the two experiences. Finally. This volunteer is the driver of the bus. I then ask what passengers (thoughts. First I ask the driver to drive while dealing with them as usual. When commitments are made from this perspective. but something is still missing: action. treating them like old friends that you invite along for the ride? 105 .. Christodoulou. & Whitfield. Oliver. I ask for a volunteer who’s willing to share a valued direction and a problematic move. 2012). Then we explore the different ways the driver might deal with the passengers. it’s always present and able to notice each piece without needing to get involved. In session 6. I coach the other group members in acting out the passengers as realistically as they can. I invite the driver to acknowledge each passenger in turn. Waltz. and in life more generally. valued life is an excellent ending to this type of work. relapses. Guenole. Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: A revised measure of 106 .. The matrix offers guidance in asking effective functional questions.. T. J. N.. This chapter simply presents some examples of metaphors and exercises that I have found to work well in groups. I prepare clients for this eventuality with the question “Would you be willing to receive your setbacks and relapses as you’ve learned to receive other experiences in this group. so you can move toward enjoying a full life with all of this and so much more?” Conclusion When working with patients with chronic pain. Orcutt. Life is full of highs and lows. R. S.. fun and energetic metaphors. it’s an outline of some things I typically do in treatment that you may find helpful when working with clients with chronic pain. the matrix can offer a useful perspective. making it broadly useful in working with clients. Beyond pain: The role of fear and avoidance in chronicity. & Norton. 97–119. D. R. These are expected. Bond. The specific perspective presented by the matrix is functional contextualism: the ability to base behavioral decisions on what works—what moves people toward their values—using acceptance of internal experiences to allow for flexible responding. Hayes.. G. W. F. and exploration of internal and external experiences. G. (2011). and I hope that you’ll find this to be the case for your practice as well. rather. Clinical Psychology Review. Baer. P. there will be setbacks. J. A. Norton.. R.The ACT Matrix Terminating Therapy Sending clients off to enjoy a full. (1999). It isn’t a treatment manual.. C. & Zettle. This work is a combination of difficult emotions... References Asmundson. in supervising and consulting with other professionals. M. K. H. G. 19(1). The matrix has been useful for me and my clients. Carpenter. and so on. including pain and suffering. K. Of course. Pain. & Olsson. 60(2)... Review of posttraumatic stress disorder and chronic pain: The path to integrated care.be/Z29ptSuoWRc. G. 107 . A. M. Pain. T. & Dobscha. C.. & Roberts. T.. controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Hayes.. L. CA: New Harbinger.. Turk. Strosahl. 12(3). M. (1999). (2011).. et al. J. (2010). Kitchens. K. Rutledge. Sandoz. Afari. Passengers on a Bus: An Acceptance and Commitment Therapy (ACT) Metaphor [Video]. European Journal of Pain. K.. 352–359. A randomized. Acceptance and commitment therapy: An experiential approach to behavior change. Psychological Record. R. Christodoulou. I. Acceptance of chronic pain: Component analysis and a revised assessment method.. (2005). A. B. Corson. Sorjonen. C. K. J. & Eccleston. (2012). C. and DuFrene. 676–688. McBeth. J. G. 40(1).. Association between substance use disorder status and pain-related function following 12 months of treatment in primary care patients with musculoskeletal pain. K. J. from http://youtu. J. Journal of Rehabilitation Research and Development. & Silman. Stoddard. Petkus. Journal of Pain. J.. 2098–2107. (2010). (2009).The Pain Matrix psychological flexibility and experiential avoidance.. & Wilson. Oliver. M. N. G... New York: Guilford. 249–272. C. S. 14(7). 753–776. 771–778. Mindfulness for two: An acceptance and commitment therapy approach to mindfulness in psychotherapy. K. K. Wicksell. Wilson. McCracken. E. The Valued Living Questionnaire: Defining and measuring valued action within a behavioral framework. The psychological inflexibility in pain scale (PIPS): Statistical properties and model fit of an instrument to assess change processes in pain related disability. 152(9). Sorrell. J. & Wilson. (2011).. (Producers).. Reno: Context Press. Gibson. G. 159–166.. J. D. Oakland. S. Dahl. K. D.. 49(5).. A. Wetherell. Luciano. J. Vowles. & Whitfield. Wilson.. 2013. G.. 95–101.. J. (2012). M. 42(4). 107(1–2). E. K. H. Morasco. T. V... L.. Acceptance and commitment therapy for chronic pain. Retrieved June 3. Hunt. K. Lekander. G. (2004). C. Macfarlane. Behavior Therapy. (2001). Risk factors for persistent chronic widespread pain: A community- based study.. Rheumatology.. . CH A P T ER 7 ACT in Digestible Bites: The Matrix and Eating Disorders Florian Saffer I work as a dietitian-nutritionist in private practice. My office is part of a medical clinic that includes physicians, psychologists, and other health professionals. General practitioners or psychiatrists generally refer clients who struggle with eating to me. This kind of outpatient care is usually multidisciplinary and coordinated by a physician. I see my job as helping my clients move toward a diet that is in line with their physiological needs and also respects their emotional needs. Rather than adhering to a standardized protocol, I prefer to help my clients become better aware of what happens when they move toward a diet more respectful of their needs. The main obstacles to their progress are generally emotional: fear of putting on weight, strict dietary rules, and so on. I have found that acceptance and commitment therapy, and especially the matrix, is perfectly suited to this task. My Matrix While doing ACT with eating-disordered clients, a strong therapeutic relationship is invaluable. As a therapist, I can be assailed by aversive thoughts and emotions just as often as my clients. I may be visited by the fear of not being up to the task or the shame of not providing effective The ACT Matrix help, or even feel irritation in the presence of an uncooperative client. When I get hooked by these thoughts and emotions, I feel the pull of away moves. At times, I can even disengage from the therapeutic relationship, which flies in the face of my therapeutic values. Using the matrix around my own experience effectively helps me become conscious of my inner experience and behaviors in session, and also helps me refocus on what’s meaningful to me. Becoming aloof Showing impatience Actively listening Remaining open ME noticing Fear of not being up to the task Shame that I could be unhelpful Being an empathic and present therapist Figure 7.1. My matrix as a therapist. I find it useful to share my own matrix with clients. It allows clients to see the similarities in our experiences. My fear of not being good enough and how the shame that comes with it can make me withdraw could resonate with a client’s experience. Clients also get that this self- revelation is a move toward a more authentic and solid therapeutic relationship. Sharing my own matrix also helps clients understand what the noticing work is about and get a sense of the use of the discriminations between inner and five-senses experiencing on the one hand, and toward and away moves on the other. Finally, sharing my own matrix allows me to let clients see the consequences of their behavior on our relationship, and thus better notice the consequences of their behaviors on their significant relationships in life (see chapter 4 for more on this type of relationship-oriented application of the matrix and ACT). 110 ACT in Digestible Bites: The Matrix and Eating Disorders Using the Matrix with Eating- Disordered Clients Folks who have a conflicted relationship with their weight or with food often experience strongly aversive emotions such as shame, anxiety, or anger. In addition, they are often entangled in inflexible rules about eating, weight management, happiness, and so on. These make up the steel from which their hooks are cast. Getting hooked by inflexible rules and difficulties in being with discomfort can pull people with eating disorders into actions to move away from what they don’t want to think or feel. The away moves that keep them stuck can take many forms: bingeing, mindlessly nibbling, restricting, obsessively counting calories ingested or burned, extreme exercising, isolating, avoiding contacts, and so on. With eating, away moves are often cyclical. The cycles may be short or long, but they invariably leave clients feeling stuck and hopeless. Interestingly, the hooks that eating-disordered clients bite often take the form of talk about what’s important. Being slim, looking like impossibly thin magazine models, or regaining self-esteem is seen as important. Yet coming to see a dietician with the goal of changing eating behaviors or losing weight is commonly an away move. Most of these clients first come knocking at my door under aversive control, aiming to move away from aversive feelings or conform to punitive standards. Therefore, it isn’t surprising that, when expressing their therapeutic objectives, these clients often say they want to feel good, stop obsessing about food, or lose weight so they can be happy. As long as they stay stuck on the left side of their matrix, they remain highly vulnerable to the struggle spiral and to relapse at some point in the future, no matter what short-term progress they may make toward their (left side) goals—a dynamic discussed in greater detail in chapter 5. Meanwhile, their lives narrow down to their experiences of what they don’t want to think or feel and their struggles against that. Overinvestment in the left side drains their lives of meaning and vitality, leaving little time and energy to engage in actions that would move them toward who or what is really important to them: loved ones, relationships, personal development, self-care, and so on. 111 The ACT Matrix The matrix can help these clients better notice their hooks and where they might get pulled when they bite—whether these hooks seemingly appear on the left, as suffering; or on the right, as things their mind claims are important, but which are really inflexible rules. The matrix can also help them differentiate between mental experiencing and inner or bodily experiencing, which in turn can help them reconnect with and better recognize sensations of hunger and satiety. Annie I have chosen to illustrate how I work with the matrix through the case of Annie. This case will help you see how I use the matrix from the first session to help clients increase their psychological flexibility. Annie’s case will also help you see how well suited the matrix is to treating clients with eating disorders and how it can be used to train the different ACT processes with this population. First Session Annie is a twenty-two-year-old law student. She comes with the goal of getting her eating behavior under control. She binges about four or five times a week, then purges by vomiting or using laxatives. When not bingeing, she follows strict dietary restrictions. She describes herself as impulsive and a perfectionist who dislikes the unexpected. Early in our first interview, she confesses to being obsessed by food. Her mind bombards her with rules about what, when, and how to eat— often contradictory: Eat a hearty breakfast and a frugal dinner, No carbohydrates if you’re not exercising, Eat your fill but not a bite more, Skip breakfast… When these show up, she easily gets hooked. When hooked, she becomes unable to fully engage with her experience of the moment. She also has difficulties contacting her inner experience. She says she has too much on her plate and is generally too stressed to know when she’s hungry or tired. She’s constantly striving to silence her food-related thoughts through sports, excessive studying, relaxation, and more, but nothing really works. When I asked Annie what she expected from our work, she answered without hesitation: “I want to feel better.” 112 ACT in Digestible Bites: The Matrix and Eating Disorders Seeing how highly fused with her thoughts Annie was and how stuck she was in struggling against them, I chose to start working on her fusion with rigid dietary verbal rules right away, using the matrix. Rather than performing a comprehensive functional analysis, I invited Annie to work with me on a recent situation illustrative of her difficulties. I thought it might be interesting to start with the right side of her matrix so that from the get-go our work would focus on ACT’s central goal: commitment to a meaningful life. Therapist: Wow, it seems your mind never stops. Minds rarely do. They love creating rules and telling us stuff. It’s quite normal. Problems arise when these rules prevent us from doing what’s meaningful to us. Could you describe to me a situation where these rules prevented you from having fun? Client: Yes, last week my best friend, Marie—she’s passionate about cuisine—invited me to this swanky restaurant. The whole evening I could only think of how much fat might be in the food, what I shouldn’t be eating, how much exercise I’d have to do to burn those calories… I just wanted the meal to be over! I was barely there. I think Marie sensed something was up. Therapist: How important is her friendship to you? Client: She’s one of the people I love the most in this world. She’s my best friend and my confidant. Therapist: Does “Friendship with Marie” go to the right of your matrix, with the important things? Client: Yes, of course! Therapist: Go ahead and write it there. 113 and enjoying a delicious dessert full of cream while chatting about fashion and stuff. our future. what comes after graduation… Therapist: And if a camera were there.2. What’s important to Annie in the situation. how would you have imagined that night? Tell me about the best possible restaurant evening with Marie. Therapist: Let’s get back to the restaurant.) . Client: I’d really be there—listen to her.The ACT Matrix FIVE-SENSES EXPERIENCING AWAY ME noticing TOWARD My friendship with Marie MENTAL OR INNER EXPERIENCING Figure 7. what would we see? Client: Two girls sharing a good meal. We’d talk about clothes. joking. Therapist: Could you place this on the matrix? Client: 114 (Points to the top right and fills it in. If you didn’t have all these rules and all this pain. our studies. Well. Therapist: Cool. our work together will be in the service of giving you a chance to choose to spend more moments like this one. Her emotional objective of wanting to “feel better” now transformed into a more behavioral one: increasing her ability to 115 . Therapist: Great! So you noticed these as possible toward moves. For a few seconds.ACT in Digestible Bites: The Matrix and Eating Disorders FIVE-SENSES EXPERIENCING Discussing fashion Appreciating a delicious dessert Sharing pleasantries Being present for Marie AWAY ME noticing TOWARD My friendship with Marie MENTAL OR INNER EXPERIENCING Figure 7. would you be willing to stay in contact with the physical sensations you experience just thinking about sharing such moments with your friend? Client: It’s kind of a warm feeling. Annie’s possible toward moves. As if I was surrounded by a gentle energy. That’s what I want. Would you be interested in that? Client: Sure. The foregoing exchange allowed Annie’s therapeutic objectives to evolve somewhat.3. ) FIVE-SENSES EXPERIENCING Discussing fashion Appreciating a delicious dessert Sharing pleasantries Being present for Marie AWAY ME noticing Anxiety Thoughts: “Don’t touch the fatty stuff” “Turn dessert down” “You’ll have to make up for all these excesses” “You’ll put on at least 5 pounds!” TOWARD My friendship with Marie MENTAL OR INNER EXPERIENCING Figure 7. What Annie doesn’t want to think or feel. My fear of piling on the pounds. And what influence did these thoughts have on what you did that day? 116 . last Friday at the swanky restaurant with Marie. Thinking about what to eat.The ACT Matrix engage in committed action (toward moves). Therapist: Where would you put these on the matrix? Client: (Points to the bottom left and fills it in. At this point. Therapist: Okay.4. Therapist: So. what prevented you from being fully present and spending the moment as you just described? Client: My anxiety. there it goes. we moved to the left side of the matrix. She’d already started opening up and becoming more flexible. and I spent my time counting calories. I drank lots of water to fill up. so this goes in the upper left of your matrix.) FIVE-SENSES EXPERIENCING AWAY Counting calories Ordering only a salad Filling up with water to eat less Pretending I can’t eat because of a tummy upset Discussing fashion Appreciating a delicious dessert Sharing pleasantries Being present for Marie ME noticing Anxiety Thoughts: “Don’t touch the fatty stuff” “Turn dessert down” “You’ll have to make up for all these excesses” “You’ll put on at least 5 pounds!” TOWARD My friendship with Marie MENTAL OR INNER EXPERIENCING Figure 7. Client: (Writes.5. 117 . Therapist: Okay.ACT in Digestible Bites: The Matrix and Eating Disorders Client: I lied. Oh. Annie’s completed matrix with her away moves in the situation. I pretended I had an upset stomach and only ordered a salad. Therapist: What feelings came along with these things you did? Client: I felt on edge…overwhelmed…frustrated… Therapist: So complying with these rules didn’t help you feel better? It sounds as though it might even have made it worse. exactly. would you say that struggling in this way helped you choose to move toward the important stuff? Client: I guess not. Annie’s away moves create more frustration and sadness and further distance her from what’s important.6. Therapist: And.) Client: Yes. turning toward what you wrote on the right side of your matrix.The ACT Matrix Client: Yes.6. Just the opposite! Moving further from this! FIVE-SENSES EXPERIENCING AWAY Counting calories Ordering only a salad Filling up with water to eat less Pretending I can’t eat because of a tummy upset ME noticing Anxiety Thoughts: “Don’t touch the fatty stuff” “Turn dessert down” “You’ll have to make up for all these excesses” “You’ll put on at least 5 pounds!” I’m frustrated and sad Discussing fashion Appreciating a delicious dessert Sharing pleasantries Being present for Marie TOWARD My friendship with Marie MENTAL OR INNER EXPERIENCING Figure 7. Could you describe the bodily sensations you experienced when you became entangled in either challenging or obeying these thoughts? 118 . Therapist: Okay. I felt so frustrated and sad! Therapist: So it kind of went around like this? (Draws the arrows on the left side in figure 7. Now let’s get back to your thoughts. I guess I’d just be able to eat when I’m hungry. Therapist: Cool. to effectively control her pain. Annie noticed two consequences of getting entangled with rigid eating rules: It didn’t allow her. and hopeful that I can get my life back to normal. Client: Well.ACT in Digestible Bites: The Matrix and Eating Disorders Client: Tense! Therapist: Do you notice a difference between how it feels to engage in toward moves versus away moves? Client: Hmm. See if you can notice this difference in your daily life. I’d rather feel the stuff on the right. 119 . and the fear that this won’t work goes in the bottom left. I asked Annie to write her thoughts and feelings regarding our first session on a new matrix. yes. Does it make a difference to see them written in black-and-white on the matrix? Client: I’m not sure. These thoughts usually come and go in your head. I’m afraid of failure. It kept her away from her friend. … Maybe it feels like they somehow reached me less? Therapist: Seeing our thoughts as natural phenomena can help us not become their slaves. At this point in our work with the matrix. in this specific context. Finally. Therapist: Could you put all of this on the matrix? Client: Eating when hungry goes in the upper right. Therapist: Could you give me an example of what you’d do differently in a “normal” life? Client: I don’t know. Thanks to the versatility of the matrix. this fear sometimes prevents me from being effective for my clients. Second Session By our second session. she’d added carbs to her lunch. For example. My emotions often paralyze me. the thoughts that invited her to engage in toward moves and those that told her to stick to away moves. To be totally honest. which she identified as a toward move. and the observing self (adopting the matrix perspective).The ACT Matrix Therapist: It’s normal for stuff to show up on the right and on the left. such as fear or shame. mindfulness (of bodily sensations). and at the same time I could notice a fear of not being up to it. Because she 120 . in her private experience. Moving toward what’s meaningful can often give rise to feelings that aren’t always pleasant. Client: Yes. committed action (spending quality time with Marie). Annie had noticed some changes in her eating behavior. in our next consultation we could look at these feelings that can prevent us from moving toward what’s important. and initiate work on values (friendship). during our consultation I wanted to help you. acceptance of unwanted emotions (anxiety). I told Annie that the goal of our work was not to modify her thoughts so much as it was to help her detach from unhelpful thoughts. I concluded our first consultation by inviting Annie to notice where some of her experiences went on her matrix over the coming week. Finally. If you want. yet she’d also felt guilty for doing so. Twice. I invited Annie to consider her food-related thoughts as natural phenomena and suggested the classical ACT exercise of prefacing her thoughts with “I have the thought that…” I then invited her to differentiate. this first session helped increase Annie’s psychological flexibility by helping her cultivate defusion (gaining some distance from food-related thoughts). We all want to avoid suffering. In an exercise inspired by one in a workshop given by Kelly Wilson. Then I debriefed the exercise using the Spiky and Flexi characters (see figure 7. And where would you place that on your matrix? Client: There. I didn’t want to think about it. as she would a crying baby. 121 . I chose to orient our second session toward training a different way to receive her discomfort—acceptance. Therapist: So where would you place struggling with suffering on your matrix? Client: To the left. Therapist: Would you say you were more like Flexi or Spiky? Client: The spiky one. We explored a number of experiential noticing exercises.7 and chapter 4) to help Annie notice how she was receiving her suffering from moment to moment. I wanted to push it away. Next. Therapist: Would you like to share what you felt during this exercise? Okay if we use the matrix? Client: Sure. I invited her to imagine her suffering leaving her body in a physicalized form.ACT in Digestible Bites: The Matrix and Eating Disorders mentioned that. but each time I tried to push it away it would just regroup. which she appreciated. Therapist: That’s perfectly natural. At first it was really hard for me to contact the situation. I invited Annie to recall a situation in which suffering was present and notice without judgment the emotions and sensations that had showed up. on the left… It was like a gray ball of dust. I invited her to imagine carrying her suffering with kindness and compassion. Third. I just wanted to stop the exercise. and more generally the culture all convey these messages in some form. wasn’t it? Annie found this exercise particularly useful. suffering increases and you become spiky. Spiky and Flexi and the matrix. she had thought of letting go as getting rid of all feelings and thoughts so as not to feel anything—something she could never do. Does that even make sense? Therapist: More Spiky or Flexi? Client: Flexi. Previously. I didn’t want to do it. Client: When you invited me to carry my suffering as I would a small child. whereas when you treat your suffering with kindness you don’t feel so stuck? Client: My brother is always going on about letting go. It’s weird because this gray cloud somehow looked like a soft and smiley monster. chasing 122 . Friends. family. I appreciated that you didn’t force me because.The ACT Matrix - - Figure 7. Emptying one’s mind. chilling out. thinking of something else.7. Messages that the frequency and intensity of emotions can or must be controlled are pervasive. Therapist: So would you say that when you struggle against what you don’t want to feel. That’s what that last part was about. the health care system. to be honest. the matrix gradually helps them sort between the hooks that appear as a function of suffering and those that contact what is truly important and vital. I always turn her down if it’s not just us two.ACT in Digestible Bites: The Matrix and Eating Disorders the blues away. Because Annie’s range of toward moves was narrow and restricted. By helping people identify the function of these verbal rules. Values Clarification and Behavioral Activation The ultimate goal of receiving one’s emotional experience is to facilitate engaging in committed actions. experiences of suffering and whether she could receive them in a similarly kind fashion. It could be an opportunity to meet people. You mentioned how the shame you feel around your body image can push you to isolate or spend hours in front of the computer. in the second session I also thought it might be useful to help her identify small steps that could represent more vital toward moves. I hate loneliness. What would be some small steps you could take toward connecting with others? Client: Marie invited me to her place for drinks with some friends from her graduate program. Therapist: As you struggle less. over the next week. But what would the Annie you want to be do in these situations? Client: See people. I’m always afraid her friends will judge me. I invited her to notice. Annie’s face looked more serene. By the end of the exercise. you may find that you have more energy for the important stuff. we all know this pull to move away from suffering. Therapist: So seeing people is important to you. Therapist: Well. and so on—all can be hooks that would seem to be on the right side and thus are commonly reported as being important. Unfortunately. it can stop us from living the life we 123 . even when suffering is intense. you can’t fail. Toward the end of our second session.” to a tug-of- war. Struggling against feelings of hunger can increase food cravings in proportion to caloric restriction and often induces strong feelings of frustration.The ACT Matrix want. Yet when evaluating the amount of energy spent on away and toward moves. bingeing can be seen as a victory of the body over the mind. I invited Annie to estimate how much energy she’d spent struggling versus moving toward what’s important to her and then write it on her matrix. Many people who struggle with eating disorders feel as if their lives are reduced to struggling and suffering. Discriminating Inner and Mental Experience During our first few sessions. In my experience. most bingeing episodes take place in the late afternoon or evening. with the body pulling to one side to get its energy supply and the mind pulling to the other to gain control. when the 124 . As long as you notice. This exercise also reinforces the notion that therapeutic work is about gradually increasing the time and energy the client invests in toward moves. which I have dubbed “the body-mind conflict. This helped her see that energy invested in struggling against unwanted experience is energy taken away from toward moves. In this respect. How would you feel about taking a risk in the direction of connecting with others? Client: I don’t know if I’m able to do that. It also served to underline that life cannot be reduced to struggle. even the most stuck clients rarely estimate that their proportion of toward moves is much below 20 percent. it became clear that Annie was having trouble noticing and respecting her sensations of hunger. I liken this phenomenon. usually over four hours after the last meal. you can choose to do it or not do it. Therapist: You know. Many people struggling with disordered eating share this difficulty. What’s important is noticing what shows up in your matrix around doing it—or not doing it. Therapist: Did you notice your mind commenting about this? Client: Yes. 125 . Therapist: Would you be willing to share your observations with me and place them on the matrix? Client: I noticed I was clenching my jaw. that I should relax. To help Annie better discriminate inner from mental experiencing. and cravings for nutrients that may provide the needed energy. The verbal rules that come with the guilt about giving in to the cravings become hooks. and on the other your experience of your mind telling you should relax? Where would you put the thought I should relax? Client: On the right. such as professional or relational stress. fueling an unending struggle between mental and inner experience. I thought that I wasn’t even realizing how stressed I was. This allowed Annie to more readily discriminate her bodily sensations from her thoughts and to notice that both inner and mental experiences are present at any given moment. and specifically figure 4. I might as well stuff myself) or renewed efforts at caloric restriction. Both lead to further turning away from food-related bodily sensations.2) can help people gradually reconnect with their bodily sensations. We then debriefed this exercise with the matrix. Therapist: Great! Do you see how both these experiences coexist—on the one hand your experience of your clenched jaw. a tendency to become more irritable (which I well recognize in my toddlers). her mind was continuing to chatter and produce thoughts. I invited her to notice how. as she was scanning her bodily sensations. I think it’s important. The physiological stress resulting from struggling against these sensations combined with other stresses. Biting those can lead to overeating (As all is lost. This physiological state is marked by disagreeable physical sensations (hunger pangs. Using a matrix that separates mental and inner experiencing (see chapter 4. can act as a catalyst for bingeing.ACT in Digestible Bites: The Matrix and Eating Disorders body is in a physiological state of hunger. a growling stomach). I suggested a body scan exercise. m. She’d felt hunger in the middle of the morning on the day after our session.The ACT Matrix Therapist: Interesting to note that our minds also tell us about important stuff. The consequences were strong feelings of frustration. and that the catastrophic scenario her mind was envisioning (You won’t be able to stop!) didn’t occur. she noticed the thought And what about eating a small snack? Maybe your body needs it. Noticing the inner experiences of eating to satiety and of overeating are crucial steps that can provide valuable 126 . which she also placed on the left. Annie noticed that she could choose to not submit to her rigid eating rules. we once again debriefed some of Annie’s observations with the matrix over the previous week. I also invited her to differentiate between thoughts that talk about what’s important and thoughts that tell her to engage in away moves. I thought. you won’t be able to stop. Multiple experiences are necessary to gradually reconnect with food-related bodily sensations before eating can come under the control of hunger. She chose to follow that thought and ate a piece of fruit and a slice of bread. Did you also notice some thinking on the left? Client: When I was scanning the sensations in my thighs. I’m a fat cow and I have to exercise more. One experience had particularly stood out. So I guess that was on the left? Therapist: Are those thoughts hooks that you readily bite? Client: Definitely! I then invited Annie to continue in this vein by noticing food-related sensations and the thoughts that coexist with these sensations. A few minutes later. which she reported as a pleasant experience. Further. She placed these thoughts on the left side. She chose to drink a cup of tea as a way to make her hunger go away. In the next session. Learning Through Direct Experience Helping Annie be able to experience the direct consequences of eating enough to appease her hunger seemed an interesting avenue for the remainder of our work. If you start eating now. She’d also noticed her mind baiting her with the hook It’s not normal to feel hungry at 10 a. ACT in Digestible Bites: The Matrix and Eating Disorders corrective feedback.. Conclusion The matrix has become essential to my practice and central to my work. The same holds true for learning new eating behaviors. I gave Annie advice on balancing her diet and eating rhythms to help her experience eating to satiety and without excess. learning to swim takes getting in the water and experimenting with several movements. The matrix is well suited to this groundwork and is a tool of choice for helping clients notice how the mind will pick up anything and turn it into rules that pull them toward experiential avoidance. Over the next several sessions. that dietary advice given to clients can all too easily be turned into inflexible rules. but being aware of her matrix helped her unhook from the struggle more readily and choose to move in the direction of respecting her bodily needs. such as reading a manual. As illustrated in this chapter. Learning to swim through verbal instructions.m. however. It is thus important to have laid the groundwork that will help clients notice these rules and how well they work before introducing dietary advice. As work with Annie progressed. Some will prove useful and will be built upon. It also helps them notice what’s important to them in broader life contexts. the frequency of her bingeing episodes dropped dramatically and her relationship to food became less conflictual. others that are less useful will disappear from the swimming repertoire. Through this work she made new friends and became part of a project that felt meaningful to her. you obviously can’t learn to swim by reading a manual. Learning any new behavior is based on successive approximations. Annie became more aware of what was meaningful to her and increasingly took steps in valued directions. She still occasionally noticed herself biting hooks such as If you eat you’ll become obese or No carbs before 3 p. In spite of her fear of being judged. However. She also volunteered for an association helping underprivileged students. such as I have to eat some carbs at every meal. Note. In addition. it’s a great tool for helping clients struggle 127 . For example. can help you orient to the most useful swimming behaviors. she started meeting friends more and isolating less. and more). health. Analyzing how they get stuck in the struggle against suffering allows clients to gradually embrace what’s important and gives their lives meaning. This allows clients to rapidly take action toward their values. 128 . the matrix is a great tool for conducting simple and effective functional analyses with my clients. friends. I love that this is not limited to disordered eating behaviors and encompasses what’s truly meaningful to clients. family. infusing their behavioral change project with rich and deep meaning. The matrix seamlessly reveals the influence of hypercontrol not only on clients’ feelings (increased discomfort). Instead of focusing on what doesn’t work. For me as a clinician. turning their lives toward appetitives and freeing them from the struggle.The ACT Matrix less and allowing them to reconnect to both what’s important to them in life and their natural experience of eating. matrix-led functional analysis plants the seeds of behavior connected to core values. but also on all life domains (partners. “symptoms” simply means behaviors that are unworkable over the longer term in a particular context—clients’ problem behaviors or struggles. at a personal and professional cost. anxiety. dependence on substances . when these very clients make small moves toward values. isolated or conflictual lives. ongoing psychotic experiences. recurrent self-destructive behaviors. I bet those with chronic and severe struggles would top the bill. unforgiving situations. or pain.” Clients with chronic and severe symptoms often cause therapists to feel frustration.CH A P T ER 8 Out of the Hole: The Matrix with Chronic and Severe Symptoms Rob Purssey “I’m just tired of always having to struggle. with their resilience and humanity. and other unwanted experiences. We may struggle in our work with these clients.) These clients may face various obstacles: traumatic histories. (Note: At times I use the term “symptoms” instead of “problem behaviors” or “struggles” for the sake of workability and brevity. chronic struggles with anxiety. If I asked you to recall some clients who have really moved you. as a clinician and as a fellow human being. I’d be better off dead. over time. sadness. they can utterly transform their lives. indicative of an underlying disease or disorder. marginal living in harsh. And yet. but this doesn’t imply symptoms in the sense used in the medical model. Here. depression. Persistent: Dysfunctional behaviors [excessive away moves] occur across time despite negative consequences. pragmatic framework that reveals workability in context.g. and emotionally defined “disorders” frees us from culturally promoted yet unworkable emotional control strategies and helps us move toward health and well-being. It allows both therapist and client to gradually let go of struggling and instead embrace moving toward more valued living. but nowhere more so than for those we might describe as having chronic and severe struggles.The ACT Matrix or multiple medications. Thankfully. Yet you may feel that current systems are inadequate for addressing the severity and apparent complexity of their symptoms. personality disorder or treatment resistant). living out true human courage in small. often unrecognized ways. role models. and severe symptoms do not equal severe problems. The functional pragmatism of the matrix gently shapes empathic change strategies. living in a particular situation. and cultural influences more than anything else. setback. from rigid. The matrix liberates us. they create meaning and purpose in their lives. We see unwanted mental experiences as they are: simply the normal emotional signals of a human with a heart and a history. Such clients often provide our greatest inspiration. 2012). The specific nature of those moves might reflect temperament. Nevertheless. the matrix provides a simple. unhelpful topographic diagnostic categories (e. More severe struggles may simply indicate a greater imbalance between away and toward moves. In his work with “challenging patients.” Kirk Strosahl (2004a) succinctly describes patterns of behavior often shown by clients with chronic and severe struggles of any kind in the following terms [with my matrix rewording after each]: Pervasive: Dysfunctional behaviors [excessive away moves] become the dominant response to almost any stress. As a conceptual and clinical tool.” in the medical model. 130 . or emotional flare-up. and our clients. Softly stepping aside from “symptoms. & Gustavsson. Chronic does not equal more broken. Robinson. Away moves are seen as functional responses that may entangle the person and persist to excess due to learned patterns (Strosahl. and more. it cuts through the surface appearances of diverse behaviors by clarifying their function.. This is important in all clinical work. and institutionally—can step back from difficult experiences and unworkable strategies and move toward more vital lives. Ways of struggling with suffering are more simply and usefully viewed functionally and pragmatically. As we tease out their values and actions in daily life and connect these to larger patterns. In this chapter. Distress producing: Dysfunctional behaviors [struggling with suffering and engaging in less valued living] cause distressing consequences to the client and others in the context of reduced self-efficacy and low motivation. unwanted experiences that can show up. The matrix point of view lets both client and clinician step back from struggling and move toward more flexibility. anxiety. clients’ valued living. By increasing our own self-compassionate. It doesn’t matter whether the label is depression. model. psychosis. clinically. rather than through the lens of a label. I’ll explore how clinicians and these challenging clients—both of whom are often in sticky situations. resulting in turn in a movement toward engagement with easing clients’ struggles and enhancing their lives. how we struggle. and movement toward values. Then I’ll explore how presence. substance use. At first. or personality disorder.Out of the Hole: The Matrix with Chronic and Severe Symptoms Resistant: Dysfunctional behaviors [excessive away moves] are difficult to extinguish in the response hierarchy because of their overlearned nature. presence. I’ll look at what’s important for us in clinical work. Clinician Matrix Notice that you are reading these words—with both your five-senses and mental experiencing. and how this can get in the way. gradual ways. and reinforce clients’ self- forgiveness. self-forgiveness. personally. in-the-moment awareness. Starting with a therapist matrix. and empirical knowledge can be useful in seeing how such struggles may be harnessed and moved with. and potential for change may seem minimal. Who is doing the noticing? Why are you reading this? What discomfort might show up that could get in the way of moving 131 . we can increase their awareness and chances of progress in tiny. we can instigate. current repertoire of toward moves. with one more client to go. Clinician’s Values The lower right quadrant of the matrix addresses what’s important to us in working with challenging clients. An ongoing. I’d rather kill myself. Imagine this scenario: You’re in the closing minutes of a session with your seventh client on a long day. undersupported work environments. empowering. notice why you’re choosing to be with that client in that moment. This client. one family at a time. From time to time during each session. especially with challenging clients.The ACT Matrix toward the values that brought you to this book? Simply notice what happens next: an away move or a toward move. This ACT stuff just isn’t helping! What 132 . simply noticing what’s happening for us in each quadrant of the matrix focuses and amplifies our awareness. The matrix provides a simple and effective orienting tool. If what shows up is I’m not choosing. engages in self-harm. Clarifying and remaining aware of our own behavior in clinical work is essential. As we introduce and use the matrix framework in each session with clients. I have to. who is socially isolated and chronically suicidal. kindness. Think for a moment about what brought you to your training and your daily work as a health care professional: perhaps helping others. easing suffering. curiosity about the human condition. intentional connection with our values—gently returning to them when we inevitably drift—is essential for nurturing and sustaining ourselves. and what tiny toward move is possible in that moment. Yet when working with challenging clients in challenging situations. caring. connecting with these values from moment to moment can often be… challenging! It’s easy to lose contact with what matters during difficult clinical work or in inadequate. can you perhaps find a “choose-to” even in that moment? Clinician’s Unwanted Mental Experiencing The lower left quadrant of the matrix addresses what gets in the way of helping clients with chronic and severe struggles. Values like these are probably guiding your toward moves in this very moment. or social justice—changing the world one life. and uses numerous medications and substances. connecting. “If you’re asking me to accept the way I feel. says. and the media. blaming yourself. despair. irritation. inadequacy. getting hooked by content.” Please pause and allow yourself to fully experience the scene. essential human feelings in the service of our clients’ lives? Too often we’re highly sensitized to issues of risk. blaming the client’s family. sadness. peers. health. overanalyzing the client and yourself. for example. frustration.” Therapeutic away moves: Declining referrals. all of these are.” “She’s acting out. then notice what unwanted mental experiencing is showing up for you right now. all may well be toward moves. frustrations. not working as hard. Clinician’s Away Moves The upper left quadrant of the matrix addresses what we do to get away from the unwanted stuff we don’t want to have when helping clients with chronic and severe struggles. such as personality disorder. as separate problems: “It’s behavioral. family. the system. fear. treatment resistant. anger. embarrassment. or isolation. tuning out. inevitable with clients who have chronic and severe symptoms. If you identified feelings of anxiety. blaming the client. uncertainty. or I just might kill myself.Out of the Hole: The Matrix with Chronic and Severe Symptoms I really need is to be admitted. such as “the story” 133 . guilt.” or lack of peer support. to be put somewhere safe. through symptom control agendas. medicolegal settings.” “He’s manipulative. or the universe. or substance dependence. such as health care systems. See if you don’t recognize some of your away moves in this quick rundown of things we do to resolve our anxieties. panic. and other unwanted emotions when dealing with challenging clients (and remember. working harder. Risk is emphasized by our clinical setting and broader environment. admitting the client to the hospital. paradigms focused on medications and “disorders. Diagnosing away moves: Being hooked by topographic diagnostic models. it depends on the context). How can we make room for and gently hold these normal. abusing metaphors. relying on medications. of course. comorbidities. and professional support. as is inevitable at times. Our systems often add to our suffering. This is heightened when our personal resources are stretched in realms such as workload. done in the service of moving your clients toward their values. Clinician’s Toward Moves Finally. coherent. Personal away moves: Working harder or longer hours. The matrix functionally connects us to the contextual behavioral science point of view. 134 . This is a move toward lifelong learning and continuing professional development. daydreaming in session. working less or shorter hours. Nurturing Your Professional Self First and foremost. being overly rigid or structured. there’s more! Setting more (or less) home practice. drinking or using other substances. making too many or too few appointments.” Whew! But wait. tuning out family and friends. and in the particular context of your therapy work within the context of the client’s life and environment. comprehensive. aware. Here are some suggestions. Ongoing connection with a coherent framework is likely to be useful to us as clinicians. it’s always about the function of particular behaviors—in a particular moment.The ACT Matrix or some other ever-present “therapist bait. it’s never about form. letting sessions run over or cutting them short. and closely focused on function within a context. What’s more. which leads nicely to the next topic. forgoing exercise or leisure activities. overanalyzing or ignoring work issues. Keeping an open. I’d like you to notice that you’re doing one of these behaviors in this very moment: you’re reading these words in this book. lacking structure. being “eclectic” in model and approach. Any of the moves listed above might be fully toward or very much away. the upper right quadrant of the matrix addresses behaviors we can do to move toward what’s important to us in helping these challenging clients. wishfully thinking. Remember. engaged view allows for a functional analysis of our clinical behaviors. letting out frustrations. the foundation of the matrix—that’s simple. If only… or Needs to see a real expert. you are doing this within a conceptual framework—an important element of contextual behavioral science. and see if it doesn’t match entirely what you seek clinically.Out of the Hole: The Matrix with Chronic and Severe Symptoms Contextual behavioral science has been defined as a strategy that “seeks the development of basic and applied scientific concepts and methods that are useful in predicting-and-influencing the contextually embedded actions of whole organisms. in action. 135 . We are trying to predict and influence the actions of our clients. with precision (efficiency). models that may be useful in moving us toward “predicting- and- influencing the contextually embedded actions of whole organisms”—or they may not be. and making time for personal and professional development— and forgiving ourselves when we fail to keep to these commitments as often as we’d like. maintaining a broad connection with things we care about. scope. with precision. 2). Examine this definition closely. critically. & Wilson. exercising. individually and in groups. First. That means having manageable working hours. taking breaks. p. it’s helpful to let go of DSM and ICD categories except where necessary. within their contexts. The matrix framework enables this point of view simply. These diagnoses are simply verbal constructs. All aspects of therapy may be viewed from the perspective of contextual behavioral science. for your clients. and reinforce psychological flexibility in our clients. scope (breadth). 2012. Barnes-Holmes. & Regier. model. Letting Go of Topographic Diagnosis For you and. eating healthily. and depth (in all aspects of their lives). such as for reimbursement and clinical communications (and the latter only with caution. in the ongoing moment. it may be a good idea to nurture these processes in ourselves. 2002). and depth” (Hayes. How is this move working toward this chosen aspect of valued living? Maintaining Your Personal and Professional Well-Being In order to instigate. Most have proven to be clinically unhelpful (Kupfer. and holding labels lightly). The ACT Matrix Letting Go of “Chemical Imbalance” and Other Biomythologies Approach the literature about chemical imbalances with a critical eye. While chemistry, including your neurochemistry, is supporting your behavior as you read this paragraph (and, after reading this paragraph, your chemistry may have changed, certain behaviors making more likely), there is no evidence that chemical imbalances exist or cause dysfunctional behaviors. Dealing with “Risk” Clients with chronic and severe struggles often exhibit pervasive, persistent, resistant, and distress- producing suicidal or self- harming behaviors. These behaviors acutely raise our anxieties, both for clients’ well-being and for our professional liability. These client away moves also provoke other unwanted mental experiencing in us: frustration, anger, guilt, and so on. Therapists often work in settings with demanding risk-management protocols for addressing suicidality and self-harm. While risk-management responses to suicidality or self-harm may technically fit protocols, such moves can be counterproductive with clients who chronically present these thoughts and behaviors. Although such responses to these thoughts in a more functional client in the midst of an acute life crisis is warranted (Strosahl, 2004b), reacting to chronic suicidality with risk-management hospitalization, medication, and the like is strongly reinforcing of such behaviors, leading to poor outcomes (see Chiles & Strosahl, 2005, for a more complete discussion of this topic). Stepping back to view “risk” through the lens of the matrix, we can notice and hold our natural, inevitable reactions to suicidality and self- harm while responding more flexibly: Ah yes, there’s anxiety. Here’s frustration. I’m feeling hooked. We can notice urges to terminate therapy, to apply labels such as personality disorder, to refer these clients, to medicate, and so on. And we can identify whether these moves are away from anxiety or toward values for our clients, and for ourselves in their service. After a client has engaged in such behaviors in the past, what has been tried? What were the consequences? How can that history guide our responses in this moment? 136 Out of the Hole: The Matrix with Chronic and Severe Symptoms In this way, we notice and emphasize the normal and natural away move functions of suicidality in the client—and their consequences, which are often very effective in the short term yet very life-narrowing in the longer term. This view reframes such behaviors as attempts at problem solving, functioning as perfectly understandable moves away from unwanted mental experiences. Holding these functional analyses foremost for ourselves and our clients allows us to notice our natural anxious reactions with less entanglement. Similarly, while it’s important to minimize external reinforcers for clients’ suicidal behaviors, it’s equally important to manage our own external reinforcers for therapeutic behaviors that are reactive and “risk-averse” (and life narrowing for clients), such as inappropriate hospitalization, increasing medication, involuntary treatment, “contracts,” and so on. Simple measures include clearly documenting chronic rather than acute suicidality; clarifying our functional, empirically based harm-minimization approach; giving advice about crisis services; maintaining appropriate professional indemnity insurance; and being aware of the extensive literature supporting outpatient care of chronic suicidality and self-harming behaviors. There is no unbiased evidence supporting the use of medication to decrease the incidence or severity of self-harm or of suicidality—quite the opposite. There is evidence that, for instance, selective serotonin reuptake inhibitors often increase suicidality (Ferguson et al., 2005). Maintaining professional support, education, and supervision from within the professional communities you inhabit is critical. Persevering with Valued Actions, Sensitive to Contextual Shifts Because challenging clients may feel stuck and hopeless, we may feel the same. So how can we nurture our health and flexibility, even in barren sessions and stuck therapy? We apply the same approach we encourage for our clients: remaining open, aware, and active; forgiving ourselves when we struggle; and gently returning to our values, again and again. We do so by reinforcing our own tiny toward moves in session, noticing what happens, analyzing these interactions, and setting home practice for ourselves to take these new behaviors “on the road” and see what happens. Both we and our clients may view the smallest valued action as a meaningful toward move. 137 The ACT Matrix Summary of the Clinician’s Matrix It may be your privilege to choose to work with the most severely distressed, disturbed, and at times disturbing individuals, gently helping them move toward their chosen values. This work can bring personal suffering, yet really making a difference in these clients’ lives can also bring great satisfaction. Ongoing connection with the purpose of your work, with others also doing this work, and with the evidence supporting what you’re doing may truly help you in holding the inevitable unwanted feelings with more kindness and self-compassion, nurturing and empowering your life both at work and at home. Client Matrix with Chronic and Severe Symptoms The client in front of you is a person who cares. He or she cared enough to come to your office and be in that chair. Even if you’re seeing the person in an institution, a hospital, or a jail, that client cares enough to be willing to see a mental health practitioner, to have showered in the last day or two, to have eaten and used the toilet. But if such clients have experienced great pain over the years when getting close to people and things that really matter to them, when you ask them, “What matters to you in life? What’s important? What do you value?” they may well answer, “Nothing. I just don’t care.” Yet clients with long histories of struggling have done a lot of advance groundwork for matrix-oriented ACT therapists. They’ve taken their time really getting to know their away moves and exactly what doesn’t work in the long term. They probably have low expectations that you can help them “get rid of” emotions they don’t like. For clients with such histories, very softly and kindly exploring the left side of the matrix can be helpful. This helps them notice the simple normalcy of suffering and struggling. It’s a gentle, compassionate, experiential way of contacting the immediate relief while also noticing the long-term costs of a life lived primarily through away moves. It allows for empathically noticing all of this from the mind’s problem- solving, “protect from harm” point of view, which is amplified by a society that has come to value “feeling good” above all else. Small, collaborative 138 Out of the Hole: The Matrix with Chronic and Severe Symptoms explorations may gently move you toward a caring, compassionate therapeutic relationship with such clients. Client’s Values “Nothing man. I just don’t care. What do you mean, what matters to me?” For clients feeling a weight of pain when they dare to care, not caring can become a vital mental away move. It dulls the acute, searing pain due to the gap between what they want and what they’ve got—that sharp ache that comes from contemplating places their mind tells them they can never hope to go. “Not caring” on the other hand, brings only flatness and a dull ache, which they may prefer to the pain you’re inviting them to feel. Consider yourself the “dentist” they have come to see, perhaps reluctantly. It’s probably best to not go straight to probing the most painful tooth! Start with an Emphasis on Values Conventional clinical assessment often begins with collecting background information. Our deepest values are often to be found within “demographic” details. Simply begin to know your client as a human being by asking about those details: How old are you? Are you single, or in a relationship? Oh, for how long? What’s your partner’s name? All relationships have their ups and downs. How’s it going just now? [Or] Would you like to be in a relationship? Are you doing anything to make that happen? So do you work, or are you in training or on benefits of some kind? How’s the job going? Are you happy enough with it? [Or] It must be hard getting by on that. Any kids? What are their names and ages? What are they up to in life? Do you live in a house or flat? Is it a rental, or yours and the bank’s? Do you have enough space, and is it comfy? How long have you been in that neighborhood? Where were you living before that? 139 The ACT Matrix As the time and setting permit, this line of questioning can gently elicit a picture of the client as a human being within a context. All of this information, along with details on activities of daily living, subtly connects with what matters, or could matter, without using scary words like “values” or “caring.” Given time, we might expand this, catching even tiny ways of passing the time, like watching TV and which shows, reading, browsing the Internet, exercise, relationships with friends and family members, pets, and so on, both currently and in the past, before the client got so stuck. You might ask questions like, “As a kid, what did you do in school?” Covering this ground is worth at least a third of assessment time. Make it clear that this is the important stuff—a rough guide to where the client might go on a life journey toward valued living. If the client is living an impoverished life in which values have seemed unapproachable, keep it gentle and light. Continue with an Emphasis on Values Begin and end each clinical encounter by touching on purposeful living. Notice small toward moves and instigate more. This engages and immediately reinforces in-session and “on the road” toward moves. Begin or end with exercises in “just noticing” (aka mindfulness) that emphasize values, from coming to and being in session to daily activities. Another possibility is a matrix warm-up of “just noticing” the feel of toward and away moves. Notice increased presence, emotional openness, and flexible engagement in the client and reinforce these moves, checking out how this reinforcement functions. Remember always that in our pain we find our values, so tease out and gently note, in a way that best fits the moment, the caring that underlies each expression of suffering. You might ease into it by simply asking “what if” something could happen in those realms. Openly and authentically appreciate any courageous move toward values in session and in daily life, no matter how tiny. Touching on values can so easily be painful. Even as I write this, my mind is giving me a hard time for often going too quickly into clients’ caring, and therefore into their pain. Asking, “Is it okay to ask you about what might really matter to you?” can be just as critical as asking, “Is it okay for us to do this exposure exercise?” 140 depression. resistant. guilt. and distress producing due to temperament. and also de- emphasize the finer details of that suffering. including you. struggle. Observable away moves include isolation. Kindly ask how often they’ve tried this approach in the past and how well it has worked. family. drugs. Rather. and individual. anger. Overanalyzing their unwanted experiencing may get in the way of moving toward valued living—which leads us nicely to the next topic. and social contexts. While their previous change efforts have probably focused on the details of unwanted experiencing and how to get rid of it. and more. exercising to de- stress. loneliness. They’re simply more pervasive. persistent. and that this is normal. panic. overworking. Client’s Away Moves Clients’ challenging solutions to suffering aren’t inherently different than those of any other human being. So you can express deep concern for their pain and suffering. and 141 . and distress. bottling up feelings. stuff shows up on the left side of their matrix and gets in the way: anxiety. Make it clear that you assume everyone suffers. As matrix practitioners. bingeing. Also ask what a focus on analyzing difficulties has cost them. engaging in therapy. it simply acknowledges that. venting. role models.Out of the Hole: The Matrix with Chronic and Severe Symptoms Client’s Unwanted Mental Experiences When we carefully explore where our clients want to go. restricting. cultural influences. health issues. seeking reassurance. Using the matrix allows us to step back and normalize this stuff. in some deep and important way. purging. pain. using mindfulness to relax. we humans really are all in this together. Clients’ urges to carefully analyze their suffering may create frustration in this area. Sensitively notice which unwanted mental experiences are most distressing to clients and which life situations are most painful. using alcohol. These take many forms. shame. with the matrix you’ve collaboratively established a clear emphasis on what’s important to clients and their toward moves. deliberate self-harm. Emphasize that this in no way minimizes the client’s suffering. we have very different assumptions and a very different agenda from the mainstream agenda of eliminating difficult experiences. Health care and other social or legal contexts can also be highly reinforcing of common away moves. putting things off. SMART goals. and so on. it’s always about the function of the behavior—the function in that moment. By noticing from time to time whether what they’re doing in that moment feels more like a toward move or an away move. Client’s Toward Moves The client in front of you is a person who cares. noticing and reinforcing these moves.The ACT Matrix medications to get rid of “bad” feelings. less easily observed away moves. Remember. as we simply notice how they’re working for valued living. All of ACT’s committed action strategies apply to challenging clients’ toward moves: bull’s-eyes. active matrix perspective allows for ongoing functional analysis of behaviors. Mental. Emphasizing movement toward what matters to the client commences your joint work on toward moves in a reinforcing fashion. valued action plans. starting with Mike. Cultivating and reinforcing an open. clients may generalize this critical behavior to their lives. and a deeply felt need to understand or get insight. who struggles with 142 . which are often pervasive and heavily invested include dissociating and ruminating. gently connecting with values. aware. Clinical Matrix Dancing with Chronic and Severe Struggles I’d like to finish this chapter with a couple of clinical vignettes that illustrate the dance outlined above. Simply learning to notice the feel of toward moves versus that of away moves is in itself an absolutely vital toward move. In exploring the client’s life during assessment. or inner. who has moved toward health to be with you. Any of the moves listed above might be fully toward or very much away. The first toward move clients will experience in the verbal context of “toward move” is likely to occur in the course of setting up the matrix point of view. which may hook both client and therapist due to their reasonableness and inevitability. you’ve discovered something of who and what matters to this person. in that particular context in the client’s life. and together checking out how it works. Small steps may lead to big changes. and so on. Out of the Hole: The Matrix with Chronic and Severe Symptoms anxiety. Notices that the client’s socially reinforced “illness” construct serves as mental explanation for moving away from frustration. even with the frustration. but I can’t kill myself because of my damn parents. Pathetic isn’t it. despite mixed feelings. living with my parents? Ever since I had to quit work because of my depression. I’m stuck back at home. Notices his own frustration with such unworkable explanations. and with your mind giving you such a hard time. Therapist: It sounds really tough. and his own away moves in the form of thoughts about the client buying and using illness as an excuse. It’s embarrassing! Therapist’s mental experiencing: Notices that independence and family are important for the client. You know. I don’t do much. or is it yours? Do you live alone or with others? Tell me about how you spend your days—even small things. and others are important to the client. Therapist: So what’s your living situation? For example. at my age. I can hear kindness in there for your parents. What if our work could be about moving toward things like that. I’m mostly feeling suicidal. do you live in a house or an apartment? Is it a rental. sadness. like TV or perhaps exercise. I haven’t been exercising since I gained all this weight because of the meds. and shame. It sounds like being independent and a bit more active might matter to you. and substance use. feeling so stuck like that. Client: Well. my illness. Notices that in this realm the client’s experience of the unworkability of medication and its side effects might offer flexibility. who’s been diagnosed with psychosis. depression. For convenience. even in tiny ways? Now here’s an exchange with Rachel. Notices his own anxiety and urge to distance himself on hearing the client’s report of suicidality. mostly just getting stoned or popping Valium. 143 . Notices that family. health. let’s assume the therapist in these vignettes is male. Connects with his own values of helping others and engages the client in a discussion of values. Mike. relationship. I don’t know. but the voices told me I was fat and ugly—that I shouldn’t bother. notices the client’s growing repertoire of noticing how toward and away moves feel and increased capacity to share about difficulties. toward you growing your life. even though it’s hard for you—that feels like a toward move to me in this moment. How about you? Client: Yeah. courageous move on the client’s part toward health. even with frustration and uncertainty? For this moment. anyway. can we just let those voices. It’s easier to just stay home. I don’t know why we keep trying. Therapist: It seems to me that. I never get there.The ACT Matrix Therapist: How did you do with those valued actions we planned last week. Therapist: So. for you. telling me this stuff. Rachel? Did you notice making some toward and away moves? Did you practice any five-senses experiencing while showering or brushing your teeth? Did you get out for those walks? How about just noticing some of your mental experiencing—did you do that? Client: Well. I don’t really know if I want to do that stuff anyway. frustration. Notices the client’s fusion and struggle with voices and the associated anger. that I’d just yell and embarrass myself again and look stupid. Rachel. and those stories. It must for you to come here and share this with me. Therapist’s mental experiencing: Again. Is it okay for us to keep working on moving toward this. can we just notice what’s showing up for you here and now? That you’re coming here. come along for the ride? 144 . and anxiety. and closeness. yet also notices that coming to therapy with “incomplete” valued actions is a significant. I noticed some toward moves with a bit of walking. at least a little bit. growing your life matters. They don’t want me to get better. It feels really…maybe a bit each way. They don’t want me to. I hate them! Therapist’s mental experiencing: Notices his own frustration with stuckness in therapy. 396. we’ll have plenty of unwanted painful experiences. Barnes-Holmes. (2004a). and Wilson. B.).... I wish you well in your journey. (2002). K. & Hutton. New York: Springer. C. and this next moment. R. Levensky (Eds.. and the next. Handbook of forensic psychology: Resource for mental health and legal professionals (pp. Kupfer. 209–245). G. Shapiro. D. In S. Ferguson. we all might choose to explore what’s possible in this moment.. J. First. & Gustavsson. (2004b)..). San Diego: Elsevier Academic Press. Strosahl. 129–154). References Chiles. With kindness and compassion. Oakland. both theirs and ours. Strosahl (Eds. K. 145 .Out of the Hole: The Matrix with Chronic and Severe Symptoms Conclusion In working with clients with chronic and severe symptoms.. welcoming them and allowing these painful thoughts and feelings in the service of what we care about most deeply? They are so closely connected. Association between suicide attempts and selective serotonin reuptake inhibitors: Systematic review of randomised controlled trials. K.). Herbert. & Strosahl. D. S. CA: New Harbinger.. D.. Arlington: American Psychiatric Publishing. Doucette. Strosahl. K. coming along for the ride. British Medical Journal 330(7492). A research agenda for DSM–V. Gently carry them toward more valued lives for your clients. Journal of Contextual Behavioral Science 1(1–2). What if we could make a little room for these unwelcome passengers. (Eds.. O’Donohue & E.. S. C. K. E. S. & Regier. (2012). Healy. Hayes & K. M. Clinical manual for assessment and treatment of suicidal patients. D. D. D. (2005). B. Forensic and ethical issues in the assessment and treatment of the suicidal patient. Glass. DC: American Psychiatric Association. D. (2012) Contextual behavioral science: Creating a science more adequate to the challenge of the human condition. In W.. T. D. A practical guide to acceptance and commitment therapy (pp. P. Hayes. Brief interventions for radical change: Principles and practice of focused acceptance and commitment therapy. C. Robinson. J. (2005). and toward a valued path for you in your chosen work. D. 1–16. A. Strosahl. ACT with the multi-problem patient. P.. Washington. K. D. . CH A P T ER 9 Something You Can Never Forget: The Matrix and PTSD Kevin Polk and Mary Alyce Burkhart The matrix began as a way of working with clients with PTSD. First. soldiers who were struggling with their traumatic memories of the war were referred to as having “soldier’s heart. cognitive behavioral therapy.” Later terms were “shell shock” and “battle fatigue. prolonged exposure therapy. After about twenty thousand hours of reading about and doing ACT. we used a psychodynamic approach. then moved on to family systems. most people who experience trauma don’t . For well over twenty years we’ve worked with people with severe trauma memories. stress inoculation training. PTSD Only a small percentage of people who experience trauma develop PTSD. survivors of traumatic experiences such as rape and natural disasters were also known to carry the wounds of their trauma for years.” Beyond those exposed to combat. Said another way. Almost everyone intuitively understands that some people who have experienced trauma are severely troubled by memories of the trauma. After the Civil War. and finally acceptance and commitment therapy. the matrix diagram emerged. Evolution of the Matrix The matrix diagram was developed as an offshoot of prolonged exposure therapy (PE. called the avoidance cycle. cognitive behavioral. Many want nothing to do with a therapy that makes them talk about the trauma. In extreme cases. As mental health knowledge has increased. The feelings associated with the trauma memory are unpleasant. the majority of people successfully incorporate the trauma memories into their daily lives. In brief. a large percentage of people who struggle with trauma memories won’t undertake PE. One is to record clients’ trauma stories and have them listen to the recordings over and over again until the distress elicited by the story drops to an acceptable level. Soon the person avoids noisy places in order to avoid having the trauma memory. going to places they’ve avoided because they invoke too much distress. Psychodynamic. Instead.The ACT Matrix develop PTSD. many clinicians try to engage clients in other psychoeducational treatments while hoping that one day they will engage in PE. For this reason. the trauma might have occurred with a lot of noise.” the problems would immediately return once they returned to noisier life settings. in noisy places the trauma memory is recalled. 148 . One of the basic symptoms of PTSD is avoidance of reminders of the trauma memory. many approaches have been used to help people struggling with trauma memories. PE uses a couple of approaches to the trauma memory. and the person seeks to avoid the feelings. PE has proved to be an effective approach for many of the clients who will engage in this therapy. Later. 1998). Foa & Rothbaum. However. While this avoidance- centered approach probably prevented some recall of the memories while people were at the “retreat. avoidance can reach the level that the person almost never leaves home in order to avoid noisy places that might trigger trauma memories. and behavioral therapy approaches have all been tried with varying success. An early form of treatment was to send people who were struggling with trauma memories away to quiet settings in the country. For example. Anyone who knows people who struggle with trauma memories is familiar with this dynamic. The other is to have clients do in vivo exposure. the matrix diagram is one of the gentlest. In the PE form of in vivo exposure. ACT has a number of gentle ways to engage people in this in vivo process. Some of the functions of going to such a place might be to buy food. usually a rating from 1 (no distress) to 10 (intolerable distress). As you will soon see. For example. a client identifies an avoided place. this can be approached differently. From an ACT point of view. it still doesn’t pass the “doable” test for a lot of people who have long histories of struggling with trauma memories.Something You Can Never Forget: The Matrix and PTSD Acceptance and commitment therapy (ACT) can be seen as an alternative to in vivo exposure. Now the son’s birthday is coming up. 149 . They’ve practiced avoidance to such an extent that the mere thought of going to a crowded store or other dreaded place invokes so much distress that they have the urge to abuse substances to avoid this. This is measured with a subjective units of distress scale (SUDS). at some point. Even ACT practitioners often believe that the trauma must be talked about. a woman might have identified that her son is very important to her. the action of going to the store can be noticed in the context of buying a gift for a valued person. clothing. and the large. and then plans are made to go to that place. The only change necessary is that the client successfully negotiates a trip to the store and purchases a gift. with most therapies this is true. of course. the trauma memories must be talked about. She needs to buy a gift. crowded store probably has just the right thing. From this point of view. and gifts. crowded discount store. Continuing with this example. Arriving in Therapy Most people struggling with trauma memories show up to therapy fearing that they’ll have to talk about their trauma memories. and the discomfort doesn’t need to change. And. The discomfort can also be noticed in this context. but then it’s discussed in terms of the function of going to such a place. and gifts can then be discussed in terms of valued actions. an avoided place might be a large. Then the person goes into the environment and tolerates the discomfort until habituation occurs. Buying food. clothing. The avoided place is identified. While ACT in vivo sounds better than PE in vivo. For the most part. some have taken the memories and done great things in life. When asked about the trauma. “What brought you here?” or some other question. perhaps by saying something like “I have this point of view that I work from. it just means they have a choice whether or not to do so. How did that happen? Consider a unit of people. Why? It isn’t that they forgot the trauma. debilitating struggles with trauma memories. clients need not talk about their trauma memories. The outcome of treatment is in no way dependent on telling the trauma story in treatment—or anywhere else. and then we’ll return to the topic of trauma memories. We can rely on clients to reveal what they want to reveal. we prefer to show clients the point of view we’re going to use first. Would it be okay if I show you that point of view?” Although traditionally a therapist would ask. They will even report that telling the story is slightly distressing. including trauma memories— while engaging in life-affirming actions.” The matrix diagram was designed to quickly get anyone into the process of having memories—all memories. This doesn’t mean they can’t talk about them. Presenting the Matrix Process The matrix is introduced in a matter-of-fact way. This is exactly what ACT strives to do: help people accept internal experiencing while going forward with life. 150 . Indeed. When you ask them. Let’s briefly take a look at the matrix process. However. When using the matrix diagram. they can tell you about it. Matrix clinicians need not mention any type of memory. They just found a way to take the trauma story into their life. The matrix clinician is encouraged to tell clients this explicitly. “You don’t need to tell your trauma story for this treatment. Some subsequently developed PTSD but others didn’t. who suffered the same trauma.The ACT Matrix Let’s briefly return to the 70 to 90 percent of people who don’t suffer from long-term. for example. these people typically report that they didn’t repeatedly tell their trauma stories. for the purposes of informed consent. say firefighters. saying. they don’t struggle with the memories in such a way that it negatively impacts their life. they kept the stories to themselves. What kind of behaviors do you do to move away from unwanted stuff that shows up inside you? For example. 151 . To this we respond.Something You Can Never Forget: The Matrix and PTSD To date. usually omitting taste for sanitary reasons. We ask clients to put the object away from their five senses and then recall each of the sensory aspects of the object through mental experiencing. With this agreement. 3. What shows up inside you. 2. 6. such as walking toward a loved one. We ask clients to recall how it feels to move toward someone or something important to them. 5. We ask them to notice the difference between their sensory and mental experiencing of the object. we then proceed to show them the diagram in one of two ways. Some clients will say there was no difference. 2. every person we’ve asked has said that it’s okay.” The other method we use is to ask the following questions while drawing the matrix diagram. Who and what are important to you? The answers are written in the lower right of the diagram. “Great! You noticed that to you there was no difference. such as fear. usually on a whiteboard: 1. 3. or some other object. pencil. We ask clients to recall how it feels to move away from some unwanted mental experiencing. that can get in the way of moving toward who and what are important to you? These answers are written in the lower left. We ask clients to use their five senses to notice a pen. we’ve been drawing the matrix diagram on a whiteboard or other suitable surface. such as moving away from fear. Here’s an outline of the first approach: 1. someone might run from fear. with you noticing these two differences. (Note: It isn’t necessary that they notice a difference. We end by saying something like “Psychological flexibility is in the center here (drawing a circle in the center). We ask clients to notice the difference between how it feels to move toward and how it feels to move away. While we’ve been asking these six questions. These answers are written in the upper left.”) 4. all at the same time. what you do to move away. here (drawing a circle in the center. your mind can do that. and that drinking alcohol is used as an away move. What behaviors could you do to move toward who and what are important to you? These answers are written in the upper right. 152 . as in figure 9. You can say something like “When one of these unwanted experiences you noticed down here (pointing to the lower left) shows up. Then you can draw half of a circle. and what you do to move toward. the client might have noticed that fear shows up. with the label “You Noticing”). which plays out on the left side of the diagram. which one of these behaviors (pointing to the upper left) do you most often do to move away from it?” For example.1.” The Stuck Cycle No matter how the matrix is presented. what shows up and gets in the way. It’s cool.The ACT Matrix 4. We end by saying something like “Psychological flexibility is in the center. You notice who or what’s important to you. the next task is to present the avoidance cycle. you can complete the circle back down to fear. Moving away. “Does drinking get rid of the fear forever. you’d next ask.Something You Can Never Forget: The Matrix and PTSD Five-Senses Experiencing Drinking Alcohol Away YOU Noticing Toward Fear Mental Experiencing Figure 9. as in figure 9.2. Continuing with this example. or does the fear eventually come back?” Clients always answer that the fear comes back.1. At that time. 153 . do you drink. drawing smaller and smaller circles. 154 . Keep doing this. “When the fear comes back. the answer is yes. Then ask.2. and then write “Stuck” underneath “Away” on the matrix. as in figure 9. so you can draw another half circle back up to drinking. The avoidance cycle.The ACT Matrix Five-Senses Experiencing Drinking Alcohol Away YOU Noticing Toward Fear Mental Experiencing Figure 9. or whatever away behavior the client identified. or do some other away move?” Of course.3. 155 . We all have our stuck spots. Explain that everyone gets stuck in these kind of cycles. Well and truly stuck.Something You Can Never Forget: The Matrix and PTSD Five-Senses Experiencing Drinking Alcohol Away YOU Noticing Toward Stuck! Fear Mental Experiencing Figure 9.3. “Where would you sort that walking on the diagram?” Notice that the client is invited to do the sorting. The client who was smelling flowers might sort that as a mental experience. However. whereas the clinician’s mind might think. us included. Most matrix clinicians. get excited and start doing the sorting for the client. not the accuracy of the sorting. any story. The matrix practitioner might ask. The aim is to get clients accustomed to stepping back from their story in order to do the sorting—to get them to ask the questions “Is this a mental or sensory experience?” and “Is this action a toward or away move?” The next phase of the process is to generalize this ongoing asking of the two questions into life. “Where would smelling go on the diagram?” The client might continue and mention taking a walk. At any time. That’s wrong. That’s done by noticing hooks. the clinician can pause on any part of any story and ask the client to sort it. Maybe someone cuts you off in traffic. Maybe someone grabs the last cookie just before 156 . As best you can. and as they do so.The ACT Matrix Sorting After the matrix diagram is presented. To do so. engage clients in telling some story. the next stage of the process is sorting. Another important point about sorting is that the accuracy of the sorting isn’t important. a person might be telling a story and mention smelling flowers. Noticing Hooks and What Is Done Next We all have events in life that are emotionally provoking. the act of sorting is what’s important. sort the story into the four categories of the matrix diagram: Sensory experiencing Mental or inner experiencing Toward actions Away actions For example. The matrix practitioner might then ask. resist this urge and have the client do the sorting. To explore this. pause and notice your current five-senses experiencing. and enjoyable. Continue by saying. If you’re running a group. For these clients. a discussion about hooks that were noticed or not noticed ensues. you can simply say something like. Explain that all 157 . Even in an individual session. you can pause and literally mix or blend the two experiences together. you can ask. simply engage clients in a conversation about hooks. Where would you sort that trauma memory?” They are almost always sorted into the lower left of the matrix. draw your fingers together in a visual representation of a mixing action. all of our clients have said yes. Some people get excited and say things like “So I’m supposed to notice the hook and then do a toward move?” To this. lively. Because these clients are already very familiar with the matrix diagram and sorting. “And where would you sort the five-senses experiencing?” It is almost always sorted right at the top of the vertical line. Clients with trauma memories might notice that they’re especially likely to get hooked by their trauma memories and that they have trouble having those memories and getting on with productive living. Toward the end of the discussion. if you get the chance. The list of potential hooks goes on and on. Would you like to hear about it?” To date. this is usually a lighthearted discussion. ask. clients are given the homework assignment to notice hooks and what they do next. “Great! Now. “Yes. the following routine can be very helpful. with the clinician noting that the homework either will or won’t be done. “What hook do you think will show up next in your life?” Once clients predict the hook.” While saying this. At the end of the session.Something You Can Never Forget: The Matrix and PTSD you were going to walk over and get it. In the next session. Maybe someone calls you an insulting name. you would respond that. “Do you think you could notice the hook and then notice what you do next?” Essentially everyone is willing to try to remember to notice their hooks and what they do next. and that either way will work for learning. a discussion of people’s favorite hooks is likely to be humorous. sometimes trauma memories can be very troubling. “When you notice having a trauma memory. Clients are likely to tell other toward and away stories and engage in some sorting into the matrix diagram. after noticing the hook. Some clients have told me that the following mixing or blending exercise was very helpful to them. both toward and away moves should be noticed. There’s no way something so simple will work.” but we can all quickly understand why Steve Hayes and company switched to the much sexier “ACT. In addition. This is too simple. your mind is saying. The two crossed lines are very primitive and easy to stare at. it is physically distanced from the client. as it is now called in ACT. 158 . mental experiencing. The Matrix Process Explained You may have guessed that while the matrix process seems very simple. and they often tell some interesting stories about the experience. Imagine a client sitting in your office with a story to tell—a story that’s mucking up the client’s life. it’s worth a try. Some of the details of the processes going on under the hood are discussed in chapter 2. If you are like most clinicians. As the client’s story is plotted on the diagram several feet away. we’ll briefly go through some of what’s happening with a few observations specific to working with traumatic memories. You might just find that it leads to a lot more valued living for clients. the story is being taken apart through the process of pausing and sorting the story. Sorting allows new experiences of the story to be related to the story.” However. They usually have. you also draw it on a whiteboard or some other surface a few feet away from the client. a lot is going on under the surface. us included. toward behaviors. Cognitive Distancing Many people don’t know that the original name for ACT was “comprehensive distancing. you can ask clients whether they tried the mixing. However. even if it’s not discussed much. This is defusion. since it’s so simple and takes so little time. and away behaviors.The ACT Matrix they need to do is notice what that mixing does. The client doesn’t have much distance from the story. Then you place the essential elements of the story on the diagram: five-senses experiencing. Here. During subsequent sessions. comprehensive distancing remains part of the model. As you describe the matrix. including that the story is being told in a safe place with no ill results. if any. clients can keep these memories to themselves. so the simpler “who or what is important to you” can be used to good effect in values clarification. Both are powerful reinforcers. The matrix makes this distinction obvious. Moving away from unwanted mental experiencing is negatively reinforcing. Most people who struggle with trauma memories simply don’t notice the difference between these two reinforcers. Even in the case of the “mixing” exercise outlined above. This isn’t productive. Working on Trauma Memories At no time are clients asked to discuss any trauma memory out loud. but moving toward who or what is important gets people somewhere in life. Then you’re stuck explaining how ACT values are different from family values. a client might think of the religiously and politically loaded family values when you refer to values. “who or what is important to you” corresponds to the ACT term “values. They notice these memories (and 159 . Obviously. but moving away from fear of imagined events or inner experiencing often isn’t functional. moving away from real danger (like an oncoming bus) is very functional.Something You Can Never Forget: The Matrix and PTSD Clarifying Values In matrix work. Committed Action Committed actions are inherent in the matrix and need not be taught. These actions are usually sorted in the upper right quadrant.” This is simply because the term “values” tends to carry some baggage. They are toward moves. For example. Recognizing Appetitive and Aversive Control Moving toward who or what is important usually results in positive reinforcement. whereas moving away keeps them stuck in an endless loop. and that’s part of how it helps. Present-Moment Awareness An often mentioned part of ACT is present-moment awareness. with your hands on your hips. That simply means totally buying the words you’re saying about yourself. rather. and sternly proclaim. “I am a mental health professional. “I am a mental health professional. For example. notice the reaction you get. Let’s take that further. stand up straight. including the practice of mindfulness. 160 . you might say. it isn’t mentioned in the basic matrix routines.” Again. Because “mindfulness” is another term that many people dislike for a variety of reasons. “I’m an accountant. it’s there for them to discover. no problem. In this way the matrix diagram automatically returns people to the present moment with no explicit intervention needed. to an extent it is you. They learn that reactions to trauma memories need not be automatic—they have a choice. Then try this with a stranger or someone you don’t know well. If you’re a mental health professional.” It’s easiest to think about it by first thinking of self-as-content. In much of life this is fine. next time you’re eating at a restaurant.” as noticing can only occur in the present moment. Notice that this choice is not forced upon clients. If you’re a mental health professional. You might say. After they notice a trauma memory (possibly as a hook).The ACT Matrix other mental experiences) showing up in real life. clients are drawn into choosing between moving away from or toward who or what is important.” Notice the reaction you get. “I’m a mental health professional. Instead.” If indeed you practice that profession. and then notice the choices they make after experiencing the memory. we’d like you to do the following exercise: The next time you see a loved one. Self-as-Context One of the more complex terms in ACT is “self-as-context. present-moment awareness is referenced with the word “noticing. The matrix also inherently takes into account who and what are important to the client in working with trauma memories.” Again. and proclaim to the waitperson. put your hands on your hips. stand up straight. This is basically seeing oneself being. but there’s not much flexibility. We take it in. The self-as-process perspective leaves you pretty stuck. at every level. If you buy the content of your words to such an extent. it gets processed. it gets processed…you get the picture. Self-as-process is simply seeing oneself as a processor. from the perspective of self-as-context. You can see yourself as being born. the choice that’s 161 . It’s all that “child of the universe” stuff we talk about. Further. as well. and so on. The reason self-as-context is emphasized in ACT and is absolutely inherent to the matrix process is choice.” and so on. you have maximum flexibility. it can get you stuck. It’s part of the process and occurs naturally.” “depressed. Now think about people with the labels “PTSD. You are your content and always will be. being one way as an infant. you can forget about self-as-context. The really good news is that when you work with the matrix.” “ADHD. You are what you are. No matter where you go in life.” “OCD. At the same time. Conclusion Another way of saying “self-as-context” is “psychological flexibility. and then there’s some reaction.” In matrix terms. It’s the same with food. You can note the changes in yourself over time. you can note that you have choices about what you might become in terms of your behaviors in the world. you also have a sense of the permanent self: the you that took the first breath you ever took. being another way as a toddler. From the self-as-content perspective there is no choice. You might try to process differently.Something You Can Never Forget: The Matrix and PTSD We’re only kidding! You don’t need to do that exercise—but just imagine if you did. and every breath you’ve ever taken. is fairly fixed. to no matter who you meet. In addition. people have the choice to do one of several away moves or one of several toward moves at any moment. “mental health professional” is your one and only identity. Information comes in. However. Now we can tackle self-as-context. how we process things. You are stuck. Would you feel sort of stuck? That’s the point. “Self-as-process” is the ACT term that refers to noticing how we are all information processors. E.. Try it and you’ll see what we mean. 162 . References Foa. Treating the Trauma of Rape: CognitiveBehavioral Therapy for PTSD. it’s extremely rewarding for both client and clinician. B. When clients report these toward moves. O. B. (1998). New York: Guilford Press.The ACT Matrix made is informed by the current context. The matrix facilitates ongoing practice in choosing in this way. even if you didn’t suggest at any time that choosing toward moves is necessary. they will come to you and tell you about noticing hooks and choosing toward moves. & Rothbaum. After a session or two. By far and away the most significant part of matrix work with people struggling with trauma memories is their discovery of appetitive (toward) moves. I have trained in cognitive behavioral therapy since 2003. Coming from a psychodynamic approach. France. This chapter presents my way of working with the matrix in this setting. By the time this book is published. I work under a convention with the French public health system. in acceptance and commitment therapy since 2008. I would formally work through the six processes of the hexaflex. with the inception of the matrix model. Then. I use the matrix with all my clients. The matrix allows for a contextual conversation from the very first exchanges. meaning that my fees are capped and clients are reimbursed for their sessions.CH A P T ER 10 Spot the Matrix: Psychological Flexibility in Private Psychiatric Practice Jean-Michel Vincent I am a psychiatrist in private practice in Besançon. I started to introduce contextual functional analysis to my clients right away. This gives my clients access to free psychotherapy services. without having to explain the model first. I might have reached my ten thousandth matrix session. . My sessions are thirty minutes long and I see no more than eleven clients a day. and with the matrix since its inception in 2009. When I first started working from the ACT model. From the perspective of the central “me” of the matrix. Client: 164 That’s not how it works for me at the moment! . by inviting them to point to where the different aspects of their experience go on the diagram. Therapist: A life that works is a flexible and broad life—a life where there is freedom and vitality (pointing toward the right side of the matrix). This allows them to choose a functional criterion as their truth criterion. as the exchange progresses. rather than the left. From this perspective.The ACT Matrix The Matrix in Context The matrix allows therapists to adopt a functional contextual perspective and helps clients see their experience in context. I don’t explain the matrix to clients. Flexibility shows up when clients start perceiving different aspects of their experience. It’s a “mindfulness for two” skill that doesn’t require formal mindfulness exercises. In a life that works. I invite clients to notice their experience and this perspective itself. we’re guided by what’s important to us. acting in accordance with their values rather than trying to avoid or escape suffering. rather. clients can pragmatically choose workability with respect to who or what is important rather than the away moves that suffering induces. A matrix diagram sits permanently on my desk and guides the conversation from the very first exchanges. It’s a life that looks to stories of possibilities in which our actions are in line with what’s important to us. leading to a broadening of behavioral repertoires. I guide them through the functional correspondence between their experience and the axes of the matrix—at first by pointing to the different aspects of their experience on the diagram. Pragmatism is then governed by the right side. Introducing the Perspective: An Introductory Dialogue Here’s an example of how I introduce the matrix perspective. and then. One of the first discriminations they can make is between left-side and right-side experiences. It’s a life of struggle. Having practiced this discrimination in 165 . But can life be reduced to solving these problems. away and toward. contextually there has to be something corresponding on the right. we validate the suffering (lower left) and the struggle (upper left) and observe their behaviors (both public and private) related to their struggles. What could your experience on the right side be like? Here I invite clients to notice their experiential avoidance in context so they can also notice another side to their experience—the side where what’s important guides their life and where their actions are congruent with their values. My job as a therapist boils down to inviting clients to notice these two aspects of their experience: the left and the right. to notice both the left and the right. you notice your life narrowing.Spot the Matrix: Psychological Flexibility in Private Psychiatric Practice Therapist: So how does it work for you at the moment? At this point. They observe their experience of inflexibility. so when your experience is here on the left. If they notice something on the left. clients often get caught up in limiting stories. and we share around that. I invite them to notice this discrimination through their inner experience. or should it be guided by what’s important to you? Our greatest freedom is to be able to notice the whole of our experience. such as “I can’t do this or that” or “I always do this or that. The therapist’s job is asking questions that help clients observe their experience in this wider context. establishing the away versus toward discrimination is often sufficient to get therapy moving. Therapist: Okay. Training the Toward-Away Discrimination At first I help clients discriminate between away moves (away from aversive functions) and toward moves (toward appetitive functions). In my experience.” They then turn to the left side of their matrix and notice their experience of a narrowing life due to avoidant behaviors and the attendant rigidity and harshness. Together. devoted to solving the problems you experience in the lower left quadrant by doing the actions in the upper left. For example. I also ask them to write the mental and sensory aspects of their suffering on different-colored sticky notes. Below are two of the strategies I may use. like a scientist observing a phenomenon for the very first time and taking inventory of the different aspects of their experience of it.The ACT Matrix session with the matrix diagram. something in the lower left quadrant. I spend time training this discrimination in our exchanges and help them observe their experience in context. But I still manage to do a few things on the right side.” Unconditionally validating clients’ suffering allows them to look at it for what it is: an experience of suffering. I’m stuck. Validating Suffering I unconditionally validate my clients’ experience of their suffering. I do this through questions such as “In a workable life. I invite them to slow down for a moment and look at what this experience is made of. I might then use the therapeutic relationship to help them experience more flexibility even in the presence of the content in the lower left quadrant. “I see that this is really painful for you and that you feel totally stuck. They might then say. what would you do?” When Nothing Shows Up on the Right Side Of course. When clients can’t discriminate between toward and away moves. Is this how it is for you?” I find that validating suffering often opens the door to more flexibility on clients’ part. I might say. clients start applying it to their everyday lives and come back for their next session with functional contextual stories evidencing an increase in flexibility. what would you do instead of your actions in the upper left quadrant? What would the stories that fill a life that works be for you? What did you use to do before suffering showed up? What did you do to move toward what’s important? And if you didn’t have all this stuff showing in the lower left quadrant. yes. What works well for me is to invite clients to observe whether they see anything on the right side. “Well. 166 . sometimes clients are so fused with their suffering in the lower left quadrant and so locked into the struggle against these experiences that they can’t see anything on the right side. which can then generalize out of session. It gets us stuck. Ideally. what would you do?” As their attentional repertoire broadens toward the right. In this situation. clients become better able to identify committed actions (upper right) that would move them toward a value (lower right). Revealing the Suffering-Values Connection Validating clients’ experience of suffering also allows them to see that their suffering corresponds to something very important to them and is thus the flip side of their values. a stretching of their matrix. While slowing down and observing content at the lower left. by sharing with the client that he or she feels stuck and is having trouble connecting with the client. In my experience. as soon as clients can see their suffering as the flip side of their values. Whereas suffering previously tended to push toward negatively reinforced avoidant actions (upper left).” Being Stuck Sometimes clients can be so stuck in suffering and avoidance that they feel hostility toward the therapist. It is already a toward move. the therapist may feel stuck in the left part of his or her own matrix. I may then ask. for example. In turn. the frame of coordination between suffering and values is a highly useful functional axis in the matrix. “And how is it for you?” This invites clients to notice their suffering (lower left) and away 167 . We can see the values that hide behind our suffering and that guide our lives. taking on approach functions. I often summarize functional analysis to clients thus: “Suffering is really hard! It narrows our lives. if not a pleasant one. it will start to function differently. I’d really like to help you see your suffering as a useful experience. I ask questions like “And what would a life on the right look like? What actions would you do? What do you see if you look to the right? In a broader life.Spot the Matrix: Psychological Flexibility in Private Psychiatric Practice Observing their experience represents a broadening. Being stuck need not be a problem in itself as long as the therapist doesn’t make a problem of it. Seeing what’s important can give a direction to our actions that isn’t just moving away from suffering. the therapist can adopt a matrix perspective on his or her experience in the moment and initiate a toward move. a valued action. which would you want to choose?” Reinforcing Toward Moves In my experience. In such cases. 168 . we get back to functional analysis with the matrix. clients often choose moving toward. I seek to reinforce this by praising the courage it takes to do that. does closing down in relationships work? If the client says no. thus promoting generalization of the behaviors practiced in session. in relationships. There will be further opportunities to come back to a contextual functional analysis through the matrix. Clients often note that they felt we were moving toward one another. After a few minutes of sharing what we notice ourselves feeling and thinking. Making Space for Resistance If clients say yes. I reveal my own matrix and invite clients to do likewise. I might then model flexibility by validating that sometimes the stuff in the lower left can be so painful that the only option appears to be trying to move away from it by closing down—for example. I then note that the client just engaged in a toward move in the presence of feeling stuck in suffering and ask whether the client noticed a difference in the experience of feeling stuck and moving away and the experience of feeling stuck and moving toward. Sometimes clients feel so stuck that they say they’d choose to move away. especially in the presence of intense suffering. In other words. I then ask clients whether applying such skills in life could make a difference. “In the presence of feeling stuck.The ACT Matrix moves (upper left) in the therapeutic relationship itself. I ask clients whether they felt we were moving closer to or further away from one another while sharing around feeling stuck. including an experience of stuckness. allows clients to notice their experience in context and gradually shapes flexibility and a broadening of their behavioral and attentional repertoire. Then I ask. and I seek to reinforce that by validating and sharing my own experience of moving closer. I may ask clients if choosing to stay on the left makes that suffering go away. I model flexibility by validating their experience that sometimes suffering is so intense that closing down seems to be the only option. Looking at any experience through the prism of the matrix. away moves work. and in which domains. Therapist: Good. I will now illustrate them with examples from my clinical practice. Her compulsions are a major impediment to her. starting with Celia. And when your head says this. What you don’t like is on the left. what do you do? Client: I get stuck! Therapist: Good. and what you really want to do is on the right. Celia Having described the skills that the matrix can cultivate. your head tells you this. you noticed that. Everybody’s touched them! Therapist: Oh yes. Therapist: And what happens when you don’t want to touch it? Client: I get stuck and I can’t do what I want. And what do you really want to do? Client: I’d like to do all the things I want to do. And does that move you toward or away from what you really want to do? 169 . Therapist: Look at this little diagram I call the matrix. doorknobs! Therapist: And what do you do when you see a doorknob? Client: I don’t want to touch it. This will prompt clients to engage in their own toward moves and promote functional generalization of new behaviors. So what do you put on there? Celia: To the left. You noticed that.Spot the Matrix: Psychological Flexibility in Private Psychiatric Practice What is important is for therapists to be themselves—to be able to choose to act on the right side of their own matrix. a ten-year-old who won’t touch doorknobs. Therapist: Good. And what’s stopping you? Client: The doorknobs. and still I did it. Do you see a connection with what you’re thinking about doorknobs? Client: That I could not always do what my head says? Therapist: Good. You noticed that! So. you noticed that too. Celia went home with a small paper matrix and instructions to practice noticing when the matrix showed up 170 . I was thinking that I couldn’t raise my hand. And what did you notice? Client: Well. I conducted a contextual functional analysis from the very first session. when your head tells you to do something on the left and what you really want to do is on the right. because when your head tells you not to touch the doorknob. could you practice noticing if you can see both sides of your matrix. Here’s a little exercise that could help us. and then see if you can choose what you do—whether on the right or on the left? What counts is that you can choose. So on the left is what gets you stuck. raise your hand to show me. (Raises her hand. Okay? Client: Okay. Therapist: Good. and on the right what you really want to do.The ACT Matrix Client: Away. using the matrix as the perspective from which to conduct the clinical conversation. Therapist: Yes. Try to have the thought I can’t raise my hand. Celia. but my head tells me fifty people have touched this doorknob! Therapist: I see this is hard for you. What do you choose? Do you do what your head tells you and get stuck.) Therapist: Good. and when you have it. does it give you a choice? With Celia. or do you do what you really want to do? Client: I’d choose what I really want to do. He has anxiety attacks that bring tremors and uncontrollable head shaking. What’s important to you that gets left behind? Client: I don’t do anything anymore.Spot the Matrix: Psychological Flexibility in Private Psychiatric Practice in her life. I saw the two sides. left and right. Therapist: And does that stop you from doing things that would be important to you? Client: I don’t do anything anymore. when everything we do is in the service of moving away from anxiety. Therapist: Could you describe to me how these attacks feel? 171 . but it was still important to do what I really wanted. that’s when all of our actions are linked to our suffering and fears. Celia came to the second session with functional contextual stories. I invited her to conduct her own contextual functional analysis every time anxiety showed up in her life. such as “My head was saying fifty people had touched the doorknob. I spend all my time worrying about when the next anxiety attack might happen. I initiated this dialogue. He’s lost his job and lives on welfare. how is your life working? Client: I live on the left. So. but it was important to me to get through that door to do what I really wanted. I live on the left… Therapist: Living on the left. Therapist: Ouch. First I avoided touching the doorknob because of fear. Therapist: Given the stuff that shows up. After presenting the matrix and its perspective on a life that works. Is this how it works for you? Client: Yes. I touched the doorknob. In other words.” Michael Michael is stuck at home. I didn’t even go to my dentist appointment for fear of an anxiety attack. I don’t even see my friends anymore. and I saw that opening the door was possible. even with the fear. The ACT Matrix Client: My neck stiffens. Now. using this session as an opportunity to notice what’s happening right here. It would allow me to reconnect with people and look for work. Therapist: Thank you for your trust. it’s exactly how you were describing your anxiety attacks. my head twists… It’s so stupid to be like this! Therapist: So you get all these sensations and thoughts. Client: It’s happening again. I know you can understand me. can you bring your attention to your bodily sensations…and the thoughts that show up…and at the same time notice the sensations around your breathing? See if you can just notice what shows up. and for staying connected in our exchange. Would you be willing for us to continue. could you simply sort what shows up as five- senses versus mental experience. See if you can slow down and notice all this from the central point on your matrix. Could it make a difference if you could do this in your life? Client: Yes. right now? Client: You’re a doctor after all. Therapist: Congratulations for courageously staying with all of this without trying to run away. without trying to change those sensations or thoughts or push them away. the perspective from which you can notice all of this while keeping some distance from it. My neck is stiffening and I’m shaking! Therapist: Yes. So okay. Client: I can notice my bodily sensations and my thoughts. right now. and then see if you have a chance to choose to do a toward move? 172 . I can’t keep my head straight. See if perhaps you can receive them with curiosity and kindness. Therapist: Would you be willing to see if you can spot the matrix in your experience between now and next week? When you do. Therapist: And what did spending the afternoon with this group allow you to do? What was on the right? What was important? 173 . Michael had opportunity in session to notice the different aspects of his anxiety attacks while I encouraged him to notice the right side of his matrix: what’s important to him and what actions he could do in valued directions. Therapist: And where does that go on your matrix? Client: On the left. She cries a lot and feels utterly stuck in despair. It’s like last Sunday: I went on this outing with a group of people who like impressionist art and I felt so bad. When suffering is very intense. so to the left. She says her life is over. Is that also how it is for you? Client: Yes. it can make us feel stuck and become rigid. I then invited him to bring this perspective to his life. It would be better if I simply disappeared. I can’t feel good with other people anymore. Therapist: Where does this go on your matrix? Client: “I’ve lost all zest for life. and I’ve lost all zest for life. I should have stayed home and watched TV.” that’s suffering. I don’t feel like going out anymore.) Therapist: I see that there’s a lot of suffering around connecting with others. It’s linked to my suffering. Client: It’s been a year since my husband left me.Spot the Matrix: Psychological Flexibility in Private Psychiatric Practice In this example. I too feel stuck when you tell me this. (Sobs. Corrina Corrina is a forty-seven-year-old woman who’s been suffering from loneliness since the breakup of her twenty-five-year marriage. I can’t feel good with other people anymore. The ACT Matrix Client: We visited the museum and learned about this painter. Therapist: Could you notice. I could never share about art with my husband. as you were on that museum outing. including suicide. Is that how it is for you? And where do you see that on the matrix? Client: I don’t want to feel this pain inside. on the left and on the right? Client: Yes. Therapist: And as we talk about this together. Client: Yes. Therapist: When suffering is very intense. does it make us move closer to or further away from one another? Client: Closer. and it would be better if I disappeared. But my husband never had an interest. And where does sharing about art go on your matrix? Client: On the right side. that two types of experiences were present. That’s in the lower left corner. But I feel horrible. I really like art. I could share with others in the group. Therapist: I’m touched that you would share with me that art is important to you. Therapist: And yet does sharing about art with others count less when the pain is there? Does it bring you closer to or further away from other people? Client: It’s important and brings me closer. our minds can suggest that we should escape our suffering by whatever means. 174 . Courbet. Therapist: I’m also noticing that it brings us closer. so thank you for sharing about art. Here’s an excerpt from our first session. because when you choose the right side. 175 . the left side also comes along for the ride. I’ve appreciated sharing with you around your passion for painting. She resents it but is afraid to discuss it with him. Therapist: There’s a lot of suffering around your wish to have children. Gina Gina is thirty-three years old and has lived with her partner for three years. And this choice that you’re making right now. In this example. rather than letting suffering rule your life? Client: Hmm. When she opened up. Therapist: It makes me feel closer to you to hear you say that. I consistently invited Corrina to broaden her attention toward the right side as a means to help her stuck story become more flexible.Spot the Matrix: Psychological Flexibility in Private Psychiatric Practice Therapist: Would you be willing to notice how it feels inside when you share with others about art and your mind tells you that you should end it all? What do you choose to do? Client: I choose to share with others. Therapist: That’s a courageous choice to make. I reinforced this by expressing the impact her sharing had on me. but her partner has already fathered two daughters and doesn’t want more kids. She dearly wants children. How about you? Client: I’ve liked it too. I guess I’ll get back in touch with the impressionists appreciation group and see what other outings they have planned. here—could it make a difference to your life if you could make that choice for everything that shows up? Isn’t it a great freedom to be able to choose what’s important. and I feel bad. I wonder what I’m gonna do. Therapist: I see this is precious to you. I can’t discuss it anymore. He even tells me. Therapist: Would you be willing to look at how this works with two matrices? When he says. and I feel I’m moving away from him. exactly. Therapist: And how does that feel? Client: I feel stuck and I clam up. you can leave. especially considering how badly things are going with his ex. Therapist: What obstacles stand in your way? Client: He’s told me that he has enough kids as it is. 176 . Therapist: And what does that make you do? Client: I get stuck on the left too.” Therapist: How does it feel when he says that? Client: I freeze. you can leave. Therapist: As if your life has narrowed? Client: Yes. what would that contain? Client: It would be a life in which I could speak sincerely with my partner and be listened to.The ACT Matrix Client: Yes. And does clamming up make you move closer to or further away from him? Client: I think it will never be possible.” where is he in his matrix? Client: Upper left. “If you don’t like it. And what actions could move you toward that? Client: I could tell him how important it would be for me to have children. “If you don’t like it. Therapist: And a broader life. Therapist: You feel stuck. Therapist: Great! And how would you do that? Client: I’d tell him. Therapist: And do you choose to let fear control your life. But he tells me he doesn’t want more kids. Therapist: And what does that make you do? Client: Clam up. But he won’t talk about it! Therapist: And where is that on your matrix? Client: Lower left. But is what’s important to you still important to you? Client: Yes. Therapist: And does that bring you closer or further away? Client: Further. Therapist: What would moving closer look like? Client: Telling him what I feel. Therapist: So you feel stuck.Spot the Matrix: Psychological Flexibility in Private Psychiatric Practice Therapist: Well noticed. “You never want to talk about what’s important to me. … On the left? 177 . or to be guided by what’s important to you? Client: What’s important. Therapist: And what would moving toward your relationship values look like? Client: Telling him that it’s important to me that he listens and takes my wishes into account. Does that bring you closer or further away? Client: Further.” Therapist: And would that be on the right or on the left? Client: Well. the problem is him. I feel stuck.” Therapist: Great! Would you be willing to ask him what he feels around the idea of having children? It would be like asking him to show you the lower part of his matrix. In any case. Therapist: And what does that make you do? Client: It makes me move away and want to stop therapy. so yes.The ACT Matrix Therapist: It’s a judgment.) Therapist: I can see you’re moved. Client: Okay. How about you? Client: I’m on the left too. It will always be important to me to have children. it’s very painful. Therapist: When you say this. I continued to invite Gina to take the perspective of the two matrices (hers and her partner’s) to help her navigate their interactions. In this way. Client: Yes. I’m on the left of my matrix. In our second session. regardless of the result. Client: I could say. (Looks away and starts crying. Therapist: So you noticed that. something our minds tell us when we’re struggling. you could maybe move closer to what’s important to you in your relationship. And is what’s important to you less important to you? Client: No. “It’s hard for me when you won’t talk about what’s important to me. 178 . I also used the two-matrix perspective of client and therapist to work on inflexible repertoires in the context of the therapy relationship in the service of helping Gina generalize enhanced flexibility to interactions with her partner. it seems to be on the left. What could you say on the right to move closer? We often move closer to one another by sharing our feelings. and I can’t change him. Client: I think I’m not going to come back. and if we ever separated. Therapist: And where are you in your matrix right now? Client: On the left. Therapist: And where are both of you on your matrices? Client: We’re both on the left. You could also show 179 . What impact does it have on your partner when you argue? Client: He starts arguing back. You could validate what he feels and help him notice the different aspects of his experience. Therapist: And is that on the left or on the right? Client: Well. I’m wondering whether you could also do this with your partner—if he too might be moved if you told him.Spot the Matrix: Psychological Flexibility in Private Psychiatric Practice Therapist: It’s moving to see how painful it is for you. Client: Yes. I could tell him that I understand it’s hard for him to think of having children again—that I can see it’s not easy for him. You could ask him to show you his matrix. Therapist: Well noticed. Therapist: What would moving to the right look like? Client: Well. I could ask him if it’s important for him to have children and what he could do if he had more children. Arguing is often in the service of controlling fear. I’d let him see his children. it’s linked to my fear. I was moved when you told me how important it is for you to have children. but it’s not possible. He doesn’t want to hear about it. Therapist: And what would moving toward what’s important look like? Client: But I’ve already told him I’m an honest person. so it’s moving away. Therapist: Yes. which are to move toward one another if it’s important for them to live together. Client: I think I want to continue therapy so we can work on this. 180 . The therapist would encourage toward behaviors. and train both partners not to get stuck in trying to get rid of suffering by engaging in away behaviors incompatible with their relational values. It’s also possible to do couples therapy with both partners using a two-matrix perspective and noticing their interactions in session. it’s the model that’s allowed for the fastest progress toward a valued life for many of my clients. I’ve given you a sense of the flexibility of this model. Conclusion I hope that by sharing around my use of the matrix diagram in my practice as a psychiatrist in private practice.The ACT Matrix him your matrix and let him know how important it is for you to have children. In my experience. You could ask what you could do together and see if maybe he’d be touched like I was when you shared how important it is for you. what is the function of conceptualizing clinical cases? If it’s a purely intellectual exercise. case conceptualization can become an integral part of the therapeutic process and help therapy move forward. In this way.CH A P T ER 11 Casing the Matrix: A Tool for Case Conceptualization Benjamin Schoendorff Clinical case conceptualization is an exercise that often vexes students and evokes away moves in even the most experienced clinicians. It’s often thought of as a linear process that requires a thorough knowledge of both diagnostic systems and one’s chosen approach. many clinicians make do without written case conceptualization. However. Its intuitive simplicity makes it easy for the clinician to use and just as easy for clients to grasp and take an active part in conceptualizing their own case. it can serve as a powerful tool for clinical change. leading to flexible and collaborative treatment planning. The matrix diagram can be turned into an effective tool for collaborative case conceptualization. This chapter presents a matrix-based conceptualization worksheet and explains how to use it to evolve a joint conceptualization with clients. In practice. The worksheet can also double up as an instrument for tracking client progress in the most relevant dynamic clinical dimensions (symptoms and processes). when case conceptualization is evolved collaboratively with the client. no wonder busy clinicians don’t bother. rather than gathering dust in the clinician’s files. Indeed. . 1). what’s the use?» Better planning treatment Progressing as a clinician Being useful Better helping my clients Mastering a new skill Becoming more flexible Better training clinicians in ACT MENTAL EXPERIENCING Figure 11. 182 . the temptation was (and at times still is) strong to engage in various away moves. producing in equal parts self-deprecating judgments regarding my intellectual and clinical abilities.1. CONTEXT: CONCEPTUALIZING MY CLIENTS’ CASES FIVE-SENSES EXPERIENCING Procrastinating Reading stuff on the internet Making do without case conceptualizations Telling trainees they don’t need to conceptualize their cases AWAY Reading about case conceptualization Involving colleagues in developing a case conceptualization worksheet Testing the worksheet with clients Involving clients in conceptualizing their case Testing the worksheet with trainees Writing about case conceptualization TOWARD Fear Brain fog Shame Some constriction in the back of my throat «How can these people do it?» «Is there really any use to this?» «I’ll never be a proper clinician if I can’t do this» «Do I really have to do this?» «Honestly. I used to stand in awe of the case conceptualization chapters—they seemed so clever and obvious. one of my away moves was to tell trainees that case conceptualization wasn’t that important. In the context of training clinicians in ACT. Faced with this content. first among them using my computer for Internet browsing rather than case conceptualization. Yet when I was faced with writing up case conceptualizations for my clients.The ACT Matrix My Own Case Conceptualization Matrix Case conceptualization is not a natural appetitive for me. In acceptance and commitment therapy (ACT) and functional analytic psychotherapy (FAP) books. a strange fear gripped me and a kind of fog descended on my mental abilities. So in the context of conceptualizing my clients’ cases. My matrix around conceptualizing clinical cases. a lot of unwanted content showed up for me in the lower left quadrant of my matrix (see figure 11. Then my mind started chattering. and rationalizations as to how and why case conceptualization is a pointless exercise. for a client who comes to therapy seeking help in moving toward important goals. what the client does to escape what’s difficult (experiential avoidance). Through the matrix perspective. In terms of the ACT model. being useful. then perhaps move to the inner obstacles that can stand in the client’s way (lower left). it contains the most important aspects of the client’s functioning. mastering a new skill. Thus. involving colleagues in developing a case conceptualization tool. Introducing the Case Conceptualization Worksheet The matrix diagram can offer a perspective on client functioning that includes what is difficult (suffering). and becoming a more flexible clinician and trainer. An Alternative to Linear Conceptualizing Using the matrix diagram frees clinicians from having a conceptualize in a linear fashion. starting from any quadrant they like. and writing about case conceptualization. which led me to delve deeper into the matter and. as I am doing now. in collaboration with colleagues. I notice a number of things: developing my planning skills. can choose to fill in the matrix diagram in whatever way they feel most effective. and what the client does to move toward who or what is important (committed action). testing the tool with clients and involving them in conceptualizing their own cases. and finish with the toward moves the 183 . what is important (values). I became better able to notice not just the aversive functions that conceptualizing cases had for me. together with their clients. then to the away moves that such obstacles evoke (upper left). better serving my clients and trainees. They. one might start filling in the lower right quadrant. When I contact what’s important. but also a number of significant appetitive functions.Casing the Matrix: A Tool for Case Conceptualization Yet if I turn my attention to the right side of my matrix and consider what’s important to me in this context. testing the worksheet with trainees. create a conceptualization worksheet based on the matrix diagram. I can more easily identify possible toward moves: reading about case conceptualization. progressing as a clinician. down to what or who would be important in making these toward moves (values). When clients have been stuck in suffering and the struggle to escape that suffering for a long time. then what the client tends to do instead of moving toward (away moves).2. when a client presents with intense suffering and is highly stuck in moves away from that suffering. and its verso in figure 11.The ACT Matrix client would want to engage in (upper right). and finally what the client is moving away from (suffering). Alternatively. The worksheet I developed (together with Egide Altenloh and Marie-France Bolduc) is shown in figure 11. they may initially be unable to consider the possibility that anything could be important in their life beyond ending their suffering. On the other hand. (The worksheet can be downloaded as a PDF file at http://www. along with an Excel worksheet that tracks and graphs evolution of the quantified processes. and. then go up to the away moves. finally.) 184 .newharbinger.3. client and clinician may consider the toward moves. no matter what. then over to what the client may wish to do (toward) moves.com/29231. clinician and client may start by filling in the suffering quadrant. after filling in the values quadrant. This path through the matrix may ease them toward seeing that. there are people or things they value and hold important. with 0 indicating minimal flexibility in the process and 10 indicating maximal flexibility. and treatment plan. and therapist notes. The back of the worksheet (figure 11. Matrix Case Conceptualization Worksheet (front). 185 . Other features of the worksheet include a space to note the client’s initial goals.3) includes spaces for significant client history.2. The scale used for all of these ratings is from 0 to 10. maintaining factors. using ratings assigned in each session. client strengths. Conceptualizing Therapist Behaviors In a feature borrowed from functional analytic therapy.Casing the Matrix: A Tool for Case Conceptualization Matrix Case Conceptualization Worksheet Name : Initial goals: Five-Senses Experiencing Q1 Q2 Therapist toward moves Therapist away moves Away AWAY MOVES P TOWARD MOVES WHAT I DON’T WANT TO THINK/FEEL WHAT/WHO IS IMPORTANT Toward D2 Maintaining factors : Treatment plan : Q4 D1 Q3 Inner Experiencing Q1 Q2 Q3 Q4 IE Figure 11. the worksheet contains boxes where therapists can note their own toward and away moves in the context of working with a particular client. Discussing these collaboratively with the client helps foster an atmosphere of openness and reinforces the ACT stance of radical equality with clients. It also includes a table that allows therapists to quantify and track clinically relevant client processes from session to session. Matrix Case Conceptualization Worksheet (back). a collaborative case conceptualization gradually emerges from filling in the form. . Figure 11. In the rest of this chapter.186 Notes: Date Consultation Five-senses/Mental discrimination (D1) Toward/Away discrimination ( D2) Perspective-taking/Observer self (P) Away moves/Experiential avoidance (Q1) Toward moves/Committed action (Q2) Contact with what is important/Values (Q3) Suffering/Avoided content (Q4) Contact with inner experience (IE) Process tracking Client strengths Significant history 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Matrix Case Conceptualization Worksheet The ACT Matrix As client and clinician go through the matrix.3. I’ll illustrate use of the worksheet with a clinical example. Jim is supportive and always treats her kindly. she met Jim. Linda stopped working toward the end of her pregnancy. her intimate relationships grew increasingly chaotic. she decided to give it a go. She also started self- harming but stopped after graduation. and in the nine months since the birth of their daughter. She started college but dropped out after two years. She mentions having started binge- eating occasionally around that time. Linda is once again in therapy. She traces her difficulties to childhood physical abuse by her father. She has little hope that things might change but feels she needs help or she might do something stupid. They decided to move in together. Her professional life has been affected by recurrent conflicts that often got her fired. In our first session she explains that she has all her life been tormented by her emotions. The third time she nearly died from an overdose of prescription drugs. she’d start feeling that she wasn’t in the right place and would quit. After a first relationship with a boy who forced her to have sexual intercourse even though she’d said she wasn’t ready. After this she swore off intimate relationships and for a while avoided most contact with men. she’s often felt empty and had a sense that she’s not in the right place in this relationship and can’t be trusted with a baby. In spite of her fears. and end up blaming her for all the problems she caused them. temping as a filing clerk. At the end of three of these relationships. and engaged in self- harm. their nine- month- old daughter. who would immediately make excuses for her husband. They’d only been dating for three months when she accidentally became pregnant. She says she’s never dared to tell Jim everything about her past. and Ella. her forty-year-old partner. Jim would 187 . took drugs. she let him approach her and a relationship developed. Ella. a kind man who felt strongly attracted to her. In high school Linda started hanging out with peers who drank. In her last job.Casing the Matrix: A Tool for Case Conceptualization Conceptualizing a Case: Linda Linda is thirty-five years old and lives with Jim. After several unsuccessful attempts at solving her difficulties through therapy and medication. She says she could never fully confide in her mother. When no open conflict showed up. Linda has been staying at home and looking after the baby. Because he was so different from her previous partners. though he does know a little bit. she felt so “crazy” she attempted suicide. tell Linda how hard things were for both her parents. Lately. I gave her sorting exercises to explore at home. Linda asked me if she was worse than other clients and if I thought she could be helped. as well as difficulties sorting inner experience from five-senses experience. I likened her feelings to waves and suggested that Linda might be able to learn to surf so that she wouldn’t be submerged by the waves and might also be able to choose in what direction to surf. especially if the baby demands attention when Linda is feeling down and confused. She also regularly calls Jim for reassurance. When she’s alone with Ella. She regularly phones her mother for support. He readily assures her that she’s a good mother.The ACT Matrix like to get married. Linda expressed strong doubts that she could be helped. I reassured her that she was making good progress. but lately she’s started doubting that he could really mean it. She had some trouble sorting actions as away or toward moves. and that if he did. I heard her story and presented the matrix model in broad strokes. At the end of the session. In the second session. he’d leave her. Evaluating Linda’s Discrimination Repertoire The matrix serves as a visual cue to help clients operate discriminations that are likely to make a difference in their lives by helping them struggle less against what they don’t want to think or feel and improving their ability to choose to move toward what’s important to them. At the end of the first session. suggesting there might be an alternative to trying to hold back her thoughts and feelings lest she become submerged by them and do things she didn’t want to do. we pay particular attention to our clients’ ability to 188 . she sometimes fears she might hurt her. and with a strong sense that her mom doesn’t really care about her. 2005). but Linda is plagued by thoughts that he’s too good for her. I presented the matrix in more detail and invited her to start sorting her experience around a difficult situation with Ella. She says her objective is to regain her self-esteem so she can feel better and not be such a burden on Jim and a danger to Ella. She’s convinced he has no idea how damaged she really is. During our first session. As matrix clinicians. I reassured her she was no worse than others. but their conversations always leave her feeling confused and angry. that he doesn’t know who she really is. Using Jon Kabat-Zinn’s Surfing metaphor (Kabat-Zinn. This can be seen as the client’s ability to take the matrix perspective and sort from it. reflecting her difficulties in discriminating. I gave Linda a 4 on both D1 and D2. which maps onto their ability to contact the observer self and perspective-taking skills. I validated how hard things were for her. we are also interested in evaluating how well clients are able to take perspective on their experience. This time I didn’t reassure. Linda reported noticing a few new toward moves. Linda’s ability to sort with the matrix and identify items in all four quadrants inspired me to rate her at 5. as sorting one’s experience on the matrix requires enough distance from that experience to be able to place it in one of the quadrants.Casing the Matrix: A Tool for Case Conceptualization perform the two main discriminations: between five-senses experience and mental experience (discrimination 1. For session 2. or D2). 189 . The matrix conceptualization worksheet contains boxes in which to evaluate clients’ ability to operate these two central discriminations. Conceptualizing Linda’s Case Through the Matrix At the third session. I offered that we could look at how things functioned through the matrix point of view and fill the worksheet together. In this dimension. or D1). She also noted how painful it was to notice so many away moves and asked if she would ever be free from her consuming doubts. and between actions to move away from what they don’t want to feel or think and actions to move toward what’s important to them (discrimination 2. As clinicians. Linda agreed. instead. such as cooking a nice dinner for Jim and telling him about her therapy work. and eating mindfully No job to go back to Practicing flexibly noticing and choosing Maintaining factors : Away Therapist away moves Validating how tough Attending to Ella with warmth things are when she asks for attention Showing willingness Sharing more with Jim Calling Jim to ask about his day to stay present Committing to the relationship when it gets tough Researching further education options Gently encouraExercising ging toward Sharing openly with my therapist.190 Feeling empty Feeling hopeless Thoughts that I’m not in my place Fear of betrayal Thoughts that I can’t trust anyone Thoughts that if Jim knew me he’d leave me Anger Shame Guilt Sugar cravings Lack of self esteem Memories of abuse WHAT I DON’T WANT TO THINK/FEEL P 5 Therapist toward moves D2 Ella .Eating sugar Missing opportuCalling Jim for reassurance nities to validate Avoiding others/relationships Trying to convince Callinging mum for support Pushing too hard Clamming up Quitting jobs Attempting suicide Not expressing my doubts in therapy AWAY MOVES Name : The ACT Matrix . 4 72 5 8 2 Q4 Practicing D2 toward/away Q3 Feels Practicing opening up and D1 Feeling hopeful. Linda’s case conceptualization worksheet (front). then feelings & and provide support. nothing in trusting in the therapeutic her body scared and sad relationship Practicing recognising hooks and what I Inner Experiencing Jim’s willingness to provide reassurance do next Mother’s unwillingness to validate Practicing D1 5 senses/mental. moves and including my doubts opening up Q1 Q2 Five-Senses Experiencing Initial goals: Strengthen self-esteem Matrix Case Conceptualization Worksheet Yelling Blaming Drinking Reassuring Taking drugs Avoiding difficult Going shopping subjects Bingeing .being a good mother Jim . her blaming Q1 Q2 Q3 Q4 IE bodily sensations.4.having someone to share life Being a good partner Feeling good about myself A fulfilling job Health Being genuine Trusting WHAT/WHO IS IMPORTANT TOWARD MOVES 4 Treatment plan : Toward Figure 11. I’m afraid to trust anyone and I fear betrayal. Therapist: So what goes in this area—what you don’t want to think or feel. if it was me or my mum— only the blood on the tiles. (Reads them back. Therapist: Okay. there are also the memories of my father beating me up. I think if Jim knew me. I always feel like I’m not in my place. so we began filling in the lower left quadrant. but not anymore. Therapist: So those things go in the top left. I have these horrible sugar cravings. Images of blood on the kitchen floor. That’s pretty much it. 191 . I avoided getting involved with men at all. These days I’ll eat sugar or go shopping and spend money I don’t have. For a while I took drugs and self-harmed.) Okay. Therapist: So there are all these things. Therapist: Okay. so when these show up. he’d leave. I can’t remember who had been hit. And the fear…fear we’d all die. Blaming others. Drinking. so all of that goes down there. what have you done to move away or escape from them? Client: Going crazy. I just lack self-esteem. Anything else you’ve done or still do when the things in the lower left show up? Client: For a while after my suicide attempts. She chose the latter. Yelling. I feel angry and ashamed. Anything else that goes there? Client: Well. What else goes there? Client: I feel so guilty! And when I do.Casing the Matrix: A Tool for Case Conceptualization Conceptualizing the Left Side I asked Linda if she wanted to start with what was important to her or what she didn’t want to think or feel. or memories you don’t want to have? Client: There’s so much to write there! I hate feeling empty and hopeless. It was just too much. I guess if I have my doubts. and it scared me. Therapist: And quitting your jobs. I guess. Therapist: Is that a bit like when you asked me if therapy would work? Client: (Laughs.) Sometimes I also try calling my mum. I’ll try. It’s important to me that you feel you can share anything you feel and think when you’re here. (Pauses. The thing is. I just get angry because she doesn’t care about me. I start worrying again. How about we take a look at mine? Client: At yours? 192 .The ACT Matrix Therapist: Was attempting suicide also a way to move away from this (pointing to the bottom left)? Client: (Pauses. where does that go? Client: Oh. But I wouldn’t do that now.) Yes. even though I still get scared at times.) Yeah. I start boiling inside and I’ll explode or quit… Therapist: And might this happen with me too? Client: (Laughs. (Pauses. the minute I put the phone down. Therapist: So we’ve looked at your away moves. Actually it is. Client: Thanks. Therapist: What else do you do when these things show up? Client: These days I call Jim just to make sure he’s there and ask him to reassure me that he’s gonna come back. there! No question. But after a while. but that never works.) Well.) Well another thing I might do is just shut up. Therapist: That would be a shame. I may not necessarily share them. can I add a couple more things in my away moves box? (Linda nods yes. sometimes I avoid difficult subjects. I’ll put it in that other box at the upper right. so recognizing and validating your difficulties. She’s always trying to tell me what I should think. I noticed I was afraid you’d think I was incompetent. Did my reassurance work? Client: It did. But she never does. I started worrying again. that’s a toward move for me. rather than getting short-tempered with her. Therapist: Sounds like when you call Jim. I can also miss opportunities to recognize your difficulties. I have a tendency to try to convince. we turned to the right side. And what happened earlier today when I didn’t reassure you but told you I could see how hard this was for you? Client: I liked that. So that goes in the other top left box. I wish my mum could simply tell me this sometimes. These are my away moves. And when I feel confused or insecure.) Okay. Conceptualizing the Right Side After having jointly conceptualized Linda’s left side processes as well as mine. Therapist: So what would the person you want to be do instead of these away moves? Client: The number one thing for me would be taking care of Ella when she asks for my attention. so I reassured you. For example. Therapist: What would that look like? 193 . Therapist: Okay. Before I ask you about your toward moves. when you asked me to reassure you last time. I also have stuff I don’t want to think or feel. But the minute I left your office. and sometimes I do things to move away from it.Casing the Matrix: A Tool for Case Conceptualization Therapist: Sure. 194 .The ACT Matrix Client: I’d be warmer. what would we see you do? Client: I could start looking up what’s available. more encouraging. what could I see you do to move toward what’s important? Client: I could share more openly with you. That too. More motherly. I guess I’d like to be able to really commit to our relationship. I guess. and I have this dream to start studying again—if only I didn’t have such low self-esteem. calling him to ask about his day. Sure. Perhaps going back to psychology… Therapist: So researching further education options. let him truly see me. Oh. That’s bad isn’t it? Therapist: It’s tough for you at the moment. share my feelings more. so can I write “Attending to Ella with warmth when she asks for attention”? Client: Yes. Exercising. Therapist: Okay. Therapist: What else would you want to do? Client: Be more open with Jim. And in here with me. and exercising. Therapist: Do you do many of these toward moves at the moment? Client: (sadly) No. Therapist: So. Therapist: Including when you have doubts or feel you’re not in your place or being a good client? Client: (Laughs. sharing with Jim. committing to the relationship.) Yes. And for education. I guess I’d call him to ask about how his day is going rather than to check that he’s coming back. right there with trying to convince. I’d like to show my willingness to stay present with you when things get tough. Therapist: In addition to validating how hard things can get for you. though sometimes I don’t need “gently”—I need a kick in the butt! Therapist: Ouch! How do you think you’d respond if I tried to push you in the way you suggest? Client: I’d probably push back. maybe wife. so pushing goes to the left for me. being a good mother to her. I’d also like to gently encourage your toward moves and your opening up.Casing the Matrix: A Tool for Case Conceptualization Therapist Toward Moves Having helped Linda identify some toward moves.) Therapist: Okay. Do you think that would help? Client: Sure. (Laughs. Let’s explore gently first. I volunteered some of my own. we could complete Linda’s matrix by having her notice what’s important behind her toward moves. 195 . being a good partner. Linda’s Values At this point. Therapist: So what would be important to you in doing these toward moves? What important life domains would they allow you to move toward? Client: Well. Feeling good about myself. Therapist: Can I also write a couple of toward moves I’d want to do to support you? Client: Sure. for Ella. okay? Client: Okay. Having someone to share my life with. For Jim. Therapist: Is that important? Client: Very important. Clinicians can ascribe ratings to each of the matrix quadrants. … But mostly scared…and sad. A fulfilling job. Does trusting go there too? Client: Yes. So feeling good about yourself. (Writes them in the inner experiencing area. Giving numerical ratings to quadrants 1 (away moves) and 2 (toward moves) allows the clinician to track the evolution of experiential avoidance and valued action. But I don’t know if I’ll ever be able to trust again. and sad goes there. the worksheet also offers the possibility of quantifying other matrix processes. how do you feel? Client: Hopeful. Therapist: How about sharing openly? What would be important there? Client: I could really be myself—be genuine and trust again. so feeling hopeful. What else? Client: Health. Therapist: When you consider these important things and domains. Therapist: So being genuine.The ACT Matrix Therapist: Feeling good about yourself? How would these toward moves help with that? Client: I could feel I was doing the right thing. scared. Therapist: Okay. Doing so for quadrant 3 (values) 196 .) And where in your body do you feel this? Client: Uh…in my head? Quantifying Matrix Processes In addition to quantifying client discrimination repertoires and perspective taking. Therapist: Okay. we agreed on a score of 5. as she appears stuck in her head and unable to locate where feelings show up in her body. Her initial score on this dimension (IE) is 2. For Q3. do you think the fact that Jim reassures you makes it more or less likely that you’ll continue asking him for reassurance? Client: More likely.Casing the Matrix: A Tool for Case Conceptualization gives an estimate of flexible contact with values. Linda appeared to have fairly good and flexible contact with her values and what’s important to her. reflecting the fact that she can name emotions but can’t locate or describe them. The function of this discrimination is to help orient work with clients who have difficulty coming into contact with their feelings and bodily sensations. and in light of this. Linda noted that it was painful for her to think about what’s important. and a Q2 score of 2 indicated that Linda currently was doing few of the toward moves she’d like to. Therefore. Therapist: Okay. Finally. Linda is such a client. Linda and I came to some agreed values for this session. However. and rating quadrant 4 (suffering) gives a broad-brush estimate of symptom intensity. Are there things people do or circumstances that make it more likely you’ll do these away moves? For example. we added a distinction between mental and inner experiencing (discussed more fully in chapter 4). Therapist: Let’s look at the things that serve to maintain your away moves. so we agreed on a Q4 score of 8. For such clients. First I explored external maintaining factors. A Q1 score of 7 indicated a good number of away moves. Other Relevant Contextual Aspects We next turned to broader contextual aspects that have played a role in Linda’s difficulties. quantifying their inner experiencing allows for tracking of their gradual progress in reconnecting with their bodily sensations and feelings. And how about your mum? 197 . Linda’s suffering was intense. so this goes in the maintaining factors box. some “feel-good” items in this quadrant may indicate avoidant values—values that are actually a “solution” to suffering. The final dimension clinicians might be interested in is clients’ ability to contact their inner experience. Professional difficulties. He’s kind and supportive. Became pregnant by accident. Forced to have intercourse in her first intimate relationship. Conflicts or quitting. String of chaotic relationships leading to three suicide attempts. Physically abusive father. significant history comprises those elements of the client’s history that have a bearing on the functioning conceptualized on the front of the worksheet. and drug use in teenage years and early adulthood.The ACT Matrix Client: Well. Therapist: Anything else? Client: I guess the fact that I don’t have a job to go back to. drinking. Dropped out of college after two years. Here’s what I recorded for Linda: 35 years old. Relationship with Jim different. I don’t seem to be able to give up hope that she’ll respond differently. Partner Jim. 9 months old. such as significant history and client strengths. Significant History For the purposes of conceptualization. The Back of the Worksheet The back of the worksheet provides space for recording relevant contextual information. Invalidating and blaming mother. 198 . Some self-mutilation. Binge eating. 40 years old. It also provides a table to record client progress in critical processes and a space for clinician notes. Daughter Ella. Therapist: So the way she refuses to give you support actually makes you engage in more away moves? Client: Definitely. likes being with others. you had the courage to start a new relationship even though you’d been hurt so much. the last box for us to fill in is your strengths. Client: I guess so. Therapist: Would it be a toward move to open up to the positive qualities people see in you? Client: I guess so. 199 .) Great. Therapist: (Writes that down. People oriented. In fact I came here because of her. So what other qualities and strengths might people see? Client: I love my daughter. it’s hard for me to hear compliments. Therapist: So. What would you say those are? Client: I don’t know. Okay. The therapist can help them explore their strengths. Therapist: Excellent. At times I think I only have weaknesses and defects. Some clients may have particular difficulties with this. Therapist: Well. Therapist: So love of learning and discoveries. Therapist: And now the courage to start therapy again even though it didn’t work in the past. I just loved the atmosphere of togetherness. You know. What else? Client: I love learning new things and discovering new places. Can I write “courageous”? Client: Yes. I used to love meeting people and going to ball games.Casing the Matrix: A Tool for Case Conceptualization Client Strengths This box allows for an interesting conversation with clients and invites us to look at their valuable qualities. courageous. contact values. Therapist: Great. automatically produces progress-tracking graphs. Or did I say that already? I like to make a note of client strengths because they give us an idea of what to nurture—what seeds we can water to see you grow in the way you want to. Can I contribute a few I’ve noticed since we started meeting? Client: Uh…sure. Persistent. warmhearted. Therapist: Smart.newharbinger. It can also help to track symptomatic dimensions through ratings of away moves and suffering. and contact with inner experience. Client: It’s nice of you to say all these good things about me.The ACT Matrix Client: I can be persistent—when my doubts leave me alone. (The downloadable Excel worksheet.5.) The first graph tracks the evolution of Linda’s matrix quadrants.com/29231. What else? Client: I’m a good cook! And that’s pretty much it as far as I can see. 200 . available at http://www. An example of Linda’s first ten sessions is shown in figure 11. perspective taking. Therapist: I mean them. earnest. Tracking Processes Over Time The table on the back of the worksheet allows for tracking progress over time in the client’s capacity to operate the discriminations. Therapist: Okay. The second tracks discriminating. initiate toward moves. take an observer perspective. and notice inner experience. Tracking matrix quadrants. discriminations.Casing the Matrix: A Tool for Case Conceptualization Matrix Quadrants 9 8 7 6 Q1 Rating 5 Q2 4 Q3 3 Q4 2 1 0 1 2 3 4 5 6 7 8 9 10 Session Discriminations. and Inner Experience 9 8 Rating 7 6 D1 5 D2 4 P 3 IE 2 1 0 1 2 3 4 5 6 7 8 9 10 Session Figure 11. perspective taking. and inner experience over time. Perspective. 201 .5. If you do this. including it as a tool for conceptualizing your own toward and away moves in the context of working with the client. Filling the worksheet in its entirety might prove too complex for some clients. I also planned to gradually help Linda better notice her feelings and bodily sensations. which makes for a strong working alliance with the client. and mindfully choose what to do. to help her distance from unhelpful thoughts and better assess the consequences of taking the bait. then by helping her note the difference between thoughts and images and the feelings and sensations that come with them—an aspect of treatment that would include work on eating mindfully. treatment priorities can be organized and noted in the area below and left of the matrix. see if you can use the matrix part of it. Building on the fledgling strength of our therapeutic relationship. Filling in the conceptualization worksheet collaboratively is a way to train clients to sort with the matrix and take perspective. I don’t systematically use the worksheet. first by practicing the D1 discrimination.The ACT Matrix Using Case Conceptualization as a Guide to Treatment Once the conceptualization is recorded on the worksheet. so I resolved to practice D2 first. I invite you to notice where clients are flexible and to use this as a springboard to work on areas where you notice significant inflexibilities. there is no hidden conceptualization. Sorting historical factors and client strengths can also provide grist for the mill. the clinician may want to choose just the elements of the worksheet that seem most relevant. Finally. I had noticed that Linda was able to identify toward moves with relative ease. In such cases. With this approach. Strengths and Potential Difficulties Producing such a written conceptualization might feel too rigid for some clinicians. In my own practice. Furthermore. 202 . clients can see that all the dimensions of their problem and situation are taken into account. I could offer to practice opening up and trusting in session. I planned to encourage Linda to flexibly notice all aspects of her experience. I also thought of helping Linda recognize hooks and what she does in response. from the matrix point of view. Typically. I’ve found that using the conceptualization worksheet is an effective way to train therapists in using ACT and adopting the matrix point of view. and make conceptualizing a collaborative enterprise. this worksheet is perhaps most helpful to use until the clinician can sort client information almost automatically.Casing the Matrix: A Tool for Case Conceptualization With the matrix. This suggests that these ratings are not only clinically significant. but also reliable ways to look at clinical processes over time. we are always struck by the high level of inter-rater reliability. So the treatment plan in the worksheet serves more as a reminder of which processes appear to be particularly relevant for the client than as a sequential plan. session by session. It can also bring down some of the common barriers to case conceptualization that clinicians commonly encounter. an approach that trains flexibility. Keeping in mind that. including to novice ACT therapists. I’d like to encourage you to practice giving client scores. These ratings and their progression will orient treatment more effectively than a linear treatment plan could. This in turn helps them rapidly find their way through the model and become more adept at flexibly choosing which intervention might best help a given client notice and choose. though it may at first feel a bit confusing. share the conceptualization with clients. Practicing quantification of matrix 203 . on the matrix dimensions by filling out the table on the back of the worksheet or using the Excel worksheet. the main task of the therapist is to train the client in adopting the matrix point of view. in particular by providing an alternative to more linear and sequential modes of conceptualization. When my colleagues and I present these ratings in our training workshops. Lastly. It can help orient clients to the model and further train them to adopt a functional contextual point of view on their difficulties. as a background task that provides moment-to-moment pointers to effective interventions. treatment planning is rarely a linear exercise. all processes are used in nearly every session as clinician and client notice different aspects of the matrix. Conclusion The matrix diagram is well suited to helping clinicians conceptualize clinical cases. Wherever you go. In the end. and the worksheet presented in this chapter is just one possible approach to conceptualizing with it. New York: Hyperion. J. and quadrants can also give a good feel for client progress. My hope is that it may prove useful to you. your clients. and your trainees. 204 . (2005). the matrix is a tool for increasing flexibility. discriminations. Reference Kabat-Zinn. there you are: Mindfulness meditation in everyday life.The ACT Matrix processes. PA RT 3 The Matrix Outside the Box . . beaten. He and his mother have come to see me today because he’s failing in school. not knowing . They frequently present like the bewildered hobbits in the movie. Taking in the image of the student. but also determined to press on. Together. and parents. My valued direction is helping whomever is in front of me get in touch with what is important to him or her—helping people learn for themselves what works to get them where they want to go. educators. I notice that this is the context of my work with students. showing Samwise Gangee and Frodo amidst the ruins of a besieged city. and utterly confused.CH A P T ER 12 The Matrix Goes to School: Promoting Psychological Flexibility in Education Phil Tenaglia “I have a point of view that I use when I work with people. He’s coming to our alternative educational program to get a fresh start and possibly salvage his school year with the help of our teachers and support staff. the poster. Would you be willing to let me show it to you?” The sullen fifteen-year-old sitting next to me in my office looks up and nods as I rise to approach the whiteboard in front of us. They look lost. On the wall behind him hangs a movie poster from The Lord of the Rings: The Two Towers. he and I begin to sort his experiences onto the matrix. and the matrix. medications. they have been given a wide range of labels (ADHD. Kevin wove us into the matrix with all of the curiosity. and I wanted firsthand experience. and glimpses of clarity that manifest along the way. I had begun reading about the ACT experiential approach. acceptance. and his colleagues through my interest in meditation and mindfulness-based approaches to treatment. By day’s end I was hooked (standard matrix lingo). The presenter was Kevin Polk. to a conference room. and my journey into the matrix had begun. Three years and hours of consultations and matrix sessions later. Kevin began the workshop by asking for permission to show us his point of view and invited us to participate in the process he used with his clients. substance dependent. I had learned about ACT. I’ve always been a perpetual student. Learning to Ride the Matrix Bike My journey to acceptance and commitment therapy. and the seat next to the young man mentioned above began several years ago. Most of my day is spent in a small alternative educational program for secondary level students. defusion.). depressed. learning disabled. I believe that one of the best ways to influence learning in others is to be in the continual process of learning. Part clinician and part improv artist. etc. agency resources. He was there to talk about his work using ACT for trauma. oppositional defiant. so the phrase “invested in education” shows up frequently in my mind. anticipating my first ACT workshop.The ACT Matrix what to do. What I have to offer are some simple words and actions. As a longtime school psychologist and family therapist. the matrix. Each student has unique and challenging learning and behavioral issues. along with as much flexibility as I can muster. Steven Hayes. Prior to their arrival these students received academic support. Their shared experience 208 . The fact that someone is sitting in front of me means that this person hasn’t given up. That’s what brought me. and so on. Asperger’s. one cold January day. We notice that and see what shows up. I’ve experienced firsthand what two crossed lines can do to enhance learning and development for my students and myself. specialized programming. confusion. Diagnostically. They have tried many things—mostly things that haven’t worked. I spend most of my professional time in schools. I need to keep developing mine. until we get it or perhaps move onto something else. and so on).” Presenting it in this way. In the process. Traditional learning environments have taken on aversive functions. but we humans primarily learn from our experience through the process of trial and error. and I immediately adopted the matrix language view of them as stuck. Along with my enthusiasm. and they walked out more psychologically flexible than when they came in. We get on the bike. they haven’t received much positive reinforcement for school- based learning. my sense of inadequacy. It has a bidirectional effect on psychological flexibility. moving around the room. While I knew the matrix approach had potential. “Hey. as well as in the client or student. since I came from a primarily psychodynamic or family systems model. we sorted their toward moves. nonjudgmental stance. My first new move when students presented for counseling or in crisis was to turn to a previously unused small whiteboard and say. It’s as if they’re trying to get somewhere using a faulty compass. and I don’t know what I’m doing. away moves. I wasn’t telling them what to do. I was excited and eager to try it out. I noticed my apprehension. and five-senses and mental experiencing onto the whiteboard. They won’t get it. The kids were in the room with me noticing both 209 . Learning is a natural process. and so on. accepting. Individually and collectively. Following my initial exposure to the matrix. Schools focus on verbal learning. we wobble. it was nothing short of a paradigm shift. so willingness to listen showed up. I also noticed the thought If I want them to develop some new skills. The valued direction I move toward is our collective task as educators to help them get unstuck so they can more readily come into contact with what is important and rewarding to them. I was engaging in different behaviors with my students (working from the whiteboard. As far as I knew. consult with staff. and intervene with students who present with various crises. and thoughts like This won’t work. In our school program my role is to provide counseling. we fall. from an open. the matrix hadn’t been tried in schools before. let me show you this cool way of looking at things I just learned. I have never been a big fan of labels (nor are my students). and avoidance is their default position. We talked. I experienced one of the many benefits of matrix use: it promotes flexibility in the clinician or educator. which is pretty much the most important job anyone under eighteen can have in our society. getting curious about the functions of our shared languaging.The Matrix Goes to School: Promoting Psychological Flexibility in Education is they are failing in school. taking notes) and away from what they don’t want (yelling to get away from anger. instead creating space for the students to come up with new behaviors and keep going. so the next natural derivation was to begin consulting with Kevin to develop my skills and knowledge.The ACT Matrix their behaviors and their unwanted issues. I was consistently returning to the process of influencing my students and staff toward discovering what works for them. The Benefits of Riding the Matrix Bike Collaboration is engendered through the matrix process and is a natural.” 210 . When students were sorting moving toward what’s important (coming to school. I did this initially via podcasts and later through regularly scheduled Skype sessions. As I developed a functional contextual point of view. “Here’s something I’ve been doing with the kids that seems to be useful. Working with them frequently results in my feeling defeated and beat up. I began to share my developing point of view with my colleagues and started using the matrix to consult with teachers about students (more on this later). I also experienced the matrix running inside of me. evolutionary step with repeated use. I knew enough to be in the ballpark most of the time. I also noticed my own toward and away moves. sleeping to get away from sadness). I also got a bigger whiteboard. I experienced that buying the stories led to less flexibility in me and limited my problem solving. as well. The students I work with have exquisitely developed avoidance behaviors from years of not feeling good about education or being rewarded for it. I could see and feel a difference in working with the matrix process (including continuously noticing the thought It’s too simple!) as well as the pull to get into the “stuck” stories the kids presented to me in words and deeds. The urge to “fix it” was there for all of us. and we were learning not to scratch it. Simultaneously. I came into contact with my own language-based traps. going to class. I decided to present the matrix at our back-to-school in-service meeting by announcing. and they were free to choose what they would do with all of that. Frequently. and the more I looked for opportunities to apply it. In this way. I am less present. Noticing. With the matrix we get to notice them and what we do after they show up. Thoughts like I have to do something or urges to teach or impart knowledge continue to show up. It never gets old.” The hooks. resentment.) I chose our six middle school 211 . just keep coming. and so on. My next derivation was to run a regular matrix group. and it’s a wonderful way to foster my own psychological flexibility. The more I used the matrix. Hooks show up everywhere and can influence both toward moves (approaching what is important) and away moves (trying to avoid what is experienced as unwanted). I noticed that the effect on the staff was similar to that on the students. or present-moment awareness of. I learned to sort these into my matrix and stay with the process of influencing students and staff toward discovering what works for them. I was invited to present the matrix to students in some of their classes. I’m also less likely to engage in values-driven behavior. The challenge for me was to continue to promote this while noticing my hooks. Over time.The Matrix Goes to School: Promoting Psychological Flexibility in Education Educational in-service meetings are great places to catch up on sleep. Several of them began to come up with ideas about how they could use the matrix in their classrooms. Happily. so I stood before my crew with fear and trepidation. I began to introduce a shared point of view that promotes greater flexibility and less stuckness for everyone. hooks are unwanted internal and external barriers that show up and pull us toward internal experiencing and away from sensory experiencing. Choice shows up. Rather than get stuck in thoughts like This kid can’t control himself or feelings of futility. more in my head. the more rewarding it became (a toward hook). hooks is the pause that connects. are usually not far behind. Moving toward collaboration entails holding the self-as- content thinking of “self-as-expert” lightly and embracing the approach of “Let’s look at this together and see what happens. otherwise known as derivations. my goal was to notice the “stuck stuff” and what I did next (either getting more hooked or “taking it with me”). and new behaviors. of course. One of the really neat things in matrix work is noticing hooks. This leads to the humbling realization that we are all swimming in the same word soup of mental experiencing. (My initial matrix work was done in a group setting. and prone to doing something to get away from the hook. When fused with unwanted mental experiencing. and everyone hung in there. & Wilson. My colleague and talented case management partner Lynda Marasco was also beginning to use the matrix with her students and experienced the flexibility it gave her. take turns. Including the staff in the group exposed them to the matrix in the service of helping the students. Running groups with folks struggling with self-control and attentional issues is daunting and can easily become chaotic. and give feedback. Those that did use it began to use the language both for themselves and their students. Prosocial behaviors kept showing up week after week. Having plenty of art supplies and paper helped. The cool part was that none of this was being explicitly taught or targeted.” To do that. Strosahl. we practiced noticing our toward and away moves. frustration. Rambunctiousness. and we kept moving.” If a new student entered the program. 1999). We had the beginnings of systemic interventions for 212 . so we gave it a whirl. We decided to take turns so each had an opportunity to lead our weekly “sorting parties. We noticed our hooks and. using the Passengers on a Bus metaphor (Hayes. I presented the matrix point of view on the whiteboard. Our shared experiences did the rest. A great way to learn the matrix is to teach it. and they were taking on the task of sorting their experiences and learning to cooperate. My valued direction was simply promoting psychological flexibility. Each week we gathered and sorted our experiences onto the matrix. and everyone got to see everyone else from a different perspective. or as I called it “noticing if what you’re doing is getting you where you want to go. and it became a form of shorthand communication. further enhancing collaboration.The ACT Matrix students to work with and decided to include the teacher and educational assistant for maximum exposure. It was fun. Together. and confusion routinely showed up. Staff members were free to choose to use the matrix elsewhere or not. one of the students ran the introductory session. share. I held the thought of “getting somewhere” lightly and let the students be their own guides. Plunging in. It wasn’t long before the kids asked to run the group. acknowledge different perspectives. Matrix Evolution Curiosity and engagement go hand in hand with the matrix. we practiced driving our buses with our wanted and unwanted passengers. Dawn White. and they’re given credit for doing so. We have referrals throughout the school year. In the midst of failure and obdurate noncompliance. possibly. Collectively. Both of us also started using the matrix with parents who consulted with us. where students have 213 . cooperation has showed up every time. uses the keywords “noticing. “It’s great that you’re noticing that!” is “What do you want to do with it?” Using the matrix empowers his students and gives them choices. also began to use the matrix in student conferences. and several teachers started to use it in their everyday lessons and inter actions with students.” and “choices” and has them prominently displayed on his classroom wall. in secondary special education. frustration. This simple step has served to lay the groundwork for future consultations with all of them and to give them a focus and a sense of forward direction.” “flexibility.The Matrix Goes to School: Promoting Psychological Flexibility in Education influencing students based on a functional contextual approach. My goal was to invite students in and give them an experience that differed from their previous lack of success. The principal. salvaging their education. Incoming students experience from the start that they are not alone and that others are making valued choices toward attending to and. Andrew Bezila. Students entering his room are encouraged to notice internal experiences of boredom. Seeing and experiencing how matrix training promoted prosocial behaviors led me to look for ways to increase matrix trainings. and I opted for group intakes. Each person took the basic approach and adapted it to his or her particular circumstances (more derivations!). and anger when they show up. What better way than to ask them for permission to show them my point of view and start with the question “Who or what is important to you?” Parents and guardians who accompanied new students were also invited to sort their experiences. and this helped defuse escalating issues with their children. I decided to introduce the matrix at the beginning of every new student orientation. Parents’ exposure to the matrix has promoted their flexibility at home and around difficult school issues. It helped promote positive interactions and gave them a way to approach instructional and behavior management issues that got reluctant learners on board. Lynda and I developed follow-up matrix groups over the course of the academic year. He believes it’s made a difference for all of them. The question Andrew asks after saying. they look at what they can do when stuckness shows up to move toward whatever is important that day. What’s standard is getting the matrix up in front of people and asking for permission to show them my point of view. Most kids want to come. and learning consultants from our school district who refer students to us have also been exposed to the matrix. The matrix is simple. celebrate successes. I help the group back off the sticky language traps 214 . I don’t push that—you know what happens when you push kids. I’ve also introduced the matrix to workshop attendees in my capacity as the district’s nonviolent crisis intervention trainer. and What do I have to offer? and the accompanying feelings as I stood before my fellow professionals. and empowering. and consulting training work the same way. elegant. The groups are voluntary and have been well attended. and if they don’t. group. I don’t know where the matrix will take me next.” I once again had the opportunity to notice thoughts such as This won’t work. giving them a practical set of tools to use. Most recently I was asked by a good friend and colleague to lead a workshop for our state school psychology conference. Many have adapted the matrix for regular classroom use as well. the process did the rest. This way we get willingness off and running. Lynda and I co-lead. They’ll think this is stupid. and address issues that get in the way of moving toward what’s important. Staff rmembers eport that it’s incredibly useful for managing crisis situations and for noticing what works and what doesn’t. I’ve offered small workshops for them and many have attended. The students have moved toward engagement. I focus on the process and Lynda focuses on content to keep the flow going. social workers. The Matrix for Education I begin all of my individual. leading to the usual group collaboration and cooperation. The following example is for groups and is easily adapted. A consultation with Kevin yielded the title “Setting the Context for Creative Problem Solving. Our groups are voluntary. Psychologists. Once I had the matrix up on the whiteboard.The ACT Matrix the opportunity to monitor their progress. There is nothing quite like standing before a group of people with two crossed lines behind you. but I do know that it works wonderfully to help me and others using it derive new behaviors. We keep the groups small (four to six students). I then write the responses in the lower right quadrant. I usually go first.” I use my words and actions to continually bring the focus to the matrix diagram. We may or may not chat about this a bit. Lynda and I also collaborate and process a bit after each group. and label the vertical line with “World of Behaviors” and “World of the Mind. I put up the crossed lines with the arrows on the horizontal line.The Matrix Goes to School: Promoting Psychological Flexibility in Education that show up. and then sort that into the matrix with a question such as “Where does what you just said fit on the matrix?” In this way. and the time frame is around forty minutes. “Who is important to you?” either to one person or the group.1. What behaviors can I do to move toward what’s important and take the stuff inside that I don’t along for the ride? 2. Who is important to me? What is important to me? What do I want to do? Toward Away World of the Mind Figure 12. I may also add “What is important to you?” to 215 . What have I been doing to the stuff that’s getting in the way ? Is it working? Am I moving closer to what’s impoertant to me? 4. write “Toward” and “Away” on either side. World of Behaviors 3. What inside stuff has been getting in the way of moving toward what is important to me? 1. We begin by drawing the matrix up on the chalkboard or whiteboard (see figure 12. We all take turns sorting. The key is to say yes to whatever the students are verbalizing.1). The matrix for secondary school students. I ask. I groom awareness and give them credit for participation. or memories.” Groups really get into this. and then you notice more stuff you don’t want. Once we have a list. sadness. and you can get a good list going. worry. so you go up here and do this stuff (away moves). anger. or urges to do harmful things.” or report that something else unpleasant shows up. “So you feel X or have thought Y down here (pointing to the unwanted stuff below) and come up here and do Z (an away move) to get away from this stuff. “So you don’t want this stuff down here. for teens.” or.” Students share what toward moves feel like. I say something like “And all of this is the important stuff that you move toward. Most of the time it feels good. “What inside stuff.” “education. have you noticed showing up inside you that gets in the way of moving toward what’s important to you?” With new groups I may have to get things going by writing something like “fear” or “anger” as an example of something that shows up inside. As the circle of arrows gets tighter and tighter. “What kinds of things have you tried to deal with your unwanted stuff.The ACT Matrix get at valued life directions.” The point here is that something shows up. Right? Does this unwanted stuff down here go away and not come back. “smoke or do drugs. such as unwanted thoughts. like to make it go away or get rid of it?” They typically say things like “ignore it. After we record the away moves. it’s still there.” “fun. saying “Sometimes when we’re moving toward important stuff. Anger or frustration shows up inside me. All of that is sorted into the lower left quadrant of the matrix. I might give an example like “I sit in a traffic jam.” “yell.” adding.” I then slide over to the lower left and ask.” “sleep. doubt. I say. In matrix language we call these away moves because they are things people do to get away from what they don’t want to have (think fusion here). or does it show up again?” Kids usually say something like “It goes away for a while” or “No. I move to the upper left and ask. I continue. illustrating an unworkable change agenda. I complain. and all of that goes onto the board (toward moves in the upper right and their feelings about them in the lower right). we don’t like how it feels.” “think of something else. Students usually list internal content like fear.” “not go to school. and it kind of goes round and 216 . I say. feelings. depression. and we do something to get way from it. “All people have important stuff they notice themselves moving toward all of the time. Kids say things like “friends.” “family. things show up inside of us that get in the way of doing what’s important to us. I start to draw arrows going from the lower left to the upper left and back down again.” and so on. since hooks can take us either toward or away.” which highlights that there is an “I” or “me” that notices what they are doing.” “Go to school. Noticing what you’re doing gives you choice about what you do next. Next I slide over to the upper right and say.The Matrix Goes to School: Promoting Psychological Flexibility in Education round until you feel stuck.” Future discussions are in the service of everyone noticing and sorting what we’re saying onto the matrix.” or “Pay attention to the teacher. moves. You could also keep doing things to get away from what you don’t want and see if that works to get you where you want to go. The key is to stay in process through responses to their statements: “So when you put your head down in class.” If they do the homework. If they don’t. It’s fine either way. such as “toward moves” and “away moves. Along the way I may also ask the question “Who is noticing this?” Participants say “I am” or “me.” We keep it simple.” they learn to notice their behaviors. We also notice our hooks (lower right and left). Everyone agrees that it doesn’t feel good. they get credit.” “Hang out with friends. “You can either do it or not do it. We want them noticing what they do and sorting their experiences onto the matrix. You could have the feeling of being bored and do your work. You can notice yourself moving toward what’s important to you and take your unwanted stuff with you. they get credit for noticing that they didn’t do it. All of this is all done collaboratively from an open. was that a toward move or an away move?” “So you went out to the movies with 217 . We don’t tell the kids what to do. but getting stuck a lot doesn’t feel good or work to get us where we want to go. You could be angry or sad and talk to a friend. I sprinkle this question in often to encourage perspective taking and present- moment awareness. Once they get the basic language down.” I chat a bit about how everyone gets stuck sometimes and say it’s okay to get stuck once in a while. For example. I then say. We also notice if any hooks showed up. When I mention homework. you could have the thought I don’t want to be here yet still be in class. and then we notice what they did instead. or behaviors do you want to do to move toward who or what is important to you?” Kids will say things like “Talk to my mom. accepting stance. “And you can notice the moves you’re making and how they work to help you get where you want to go. The homework is to notice what you do and whether it’s a toward move or an away move. taking us back into the matrix process. “So what kinds of things. the typical response is “ugh!” I say. the groups more or less run themselves. Flexibility increases. After several months of sorting. a learning- disabled middle school student notices that she’s disturbing others in her efforts to move away from her anger. and they come up with more behaviors (derived relational responding) to keep moving in valued directions. We even overhear conversations in the hallways about toward moves versus away moves and being hooked. looks at his teacher. in response. his teacher smiles at him and helps him. obliterating the insults and the challenge. Once kids get the process down.The ACT Matrix your friends and took your sadness with you. and you can plug in your favorite ACT exercises for added enjoyment. he feels good and wants to do it more. and thoughts. and memories below—and become aware of the toward and away functions of their actions. He also notices that. and so on. She begins to slowly and calmly respond in more detail than the student wanted. She also notices that the class is more attentive and tuned in to her. does his work. She has the thought Maybe I shouldn’t do this and chooses on her own to reengage in the lesson. She notices the urge to move away from both her anger and the student and pauses.” “Where would you put that story on the matrix? Is that a story where you have lots of choices or few choices?” The kids learn to sort their experiences—behaviors up top. Prosocial behaviors show up. images. Matrix Derivations Here are some other examples of how learners and educators have used the matrix: A struggling ten-year-old student notices that when he goes to class. feelings. come up with solutions. they help each other notice their moves. A high school teacher has an image of the matrix in her head as a student fires provocative questions at her. School attendance and compliance among group attendees improves significantly. and try new behaviors. For example. It’s fun and rewarding. 218 . It may take a few sorts. and improves attention in real time with no agenda other than what the learner brings to the table. He’s able to transition from a specialized school to a public school with specialized support. we can use this point of view to influence individuals and groups to go out and discover 219 . they’re disorganized.” I see again and again how learners and educators are loosened up from aversive control and move toward increased appetitive functioning. When I asked the student I met with at the beginning of the chapter what he did with his unwanted stuff. not through textbooks or curriculums. observer self. I tell people. values. Anger is his identified internal obstacle. and amazement.The Matrix Goes to School: Promoting Psychological Flexibility in Education An eight-year-old boy with binaural sensorineural hearing loss discovers how to move toward success in education and school. and they lack attention to detail. His valued move when anger showed up is to put his anger in his backpack and take it with him. Conclusion Three characteristics define a learner in trouble: they act before thinking. his response was “I live it in me. Each act of matrix sorting— noticing toward versus away moves. He experiences satisfaction. and it’s pointed toward growing and thriving. acceptance. His mother also learns how to reward his toward moves and model flexibility. and noticing sensory experience versus internal experience versus who is noticing—is a brief flexibility training.” Then. This is knowledge gained through experience. with a big smile on his face. and committed action. Rather than having the goal of imparting knowledge. pride. My experience as a clinician and practitioner is that the matrix addresses all of these issues. “Using the matrix teaches you how to fish. organizes the learner’s experiencing. he added. “I don’t know where that came from!” The matrix helps learners of all ages notice and analyze the function of their own behaviors while targeting the core ACT processes of cognitive defusion. present- moment awareness. Promoting psychological flexibility with the matrix enhances mindful awareness and choosing valued actions. How much training someone needs to get unstuck and engage in more valued behaviors is highly dependent on the individual and the context. or it may take hundreds. group. Pretty cool stuff. This is influence with precision. C. From just two crossed lines and a few simple words and actions comes limitless variation at the individual.The ACT Matrix the knowledge and experience that works for them. 220 . S. D. (1999). Strosahl. K. and depth. scope. and organizational level. Reference Hayes. New York: Guilford. G. K.. Acceptance and commitment therapy: An experiential approach to behavior change.. & Wilson. ACT has been shown to be an effective intervention to help manage workplace stress and improve employee performance (Flaxman & Bond.CH A P T ER 13 In Business: The Matrix for Team Building and Professional Stress Annick Seys I’m a social worker. and performance anxiety but also clients who suffer from more severe psychological disorders. typically groups of psychologists. or dietitians. social workers. such as eating disorders. We also offer more tailored interventions on demand. professional stress. . intervene in teams. Hayes. 2006. I have a private clinical practice where I work with people suffering from burnout. Our clients are mostly organizations in the private social sector. and have a stress management or crisis and conflict management mandate. More recently I moved to organizational work as a cofounder of a consulting and training partnership. and we are seeing increased interest from coaches working in business environments. efficient tool that is especially effective in helping improve the atmosphere in the workplace. In my work with organizations. We teach them about acceptance and commitment therapy in six-day courses and workshops with different ACT themes. Bond. & Barnes-Holmes. I have been using ACT since 2010 and the matrix since 2011. therapists. 2006). I have found the matrix to be a practical. memories. Orienting to the right side of the matrix helps build a strong foundation for moving to defusion and acceptance. conflict (latent or open). Working with Teams I do workplace interventions among members of teams.The ACT Matrix I have been particularly impressed by how versatile and swift the matrix can be in getting the ACT point of view across. Using the matrix. Workplace communication improves. Working with the axis of mental experiencing versus the five senses lets people experience how they can get hooked by judgments. what is truly important to them. In short order. Participants become better able to step back from thoughts and feelings that can get in the way of doing what they truly want to do. consultants must tread lightly and are rarely welcomed with open arms by the team as a whole. I have seen people quickly open up and. 222 . and all of the other links the mind makes that aren’t always useful and invariably take them away from the present moment. people let go of stories about what others should change so they can at last feel better. In such an environment. dare to speak openly and kindly about what’s bothering them. most of all. along with respect for others’ opinions. personal stress. From there. and dissatisfaction with work-life balance are common. I believe these positive outcomes have to do with the fact that the matrix normalizes participants’ inner experiences from the get-go and makes them see that their colleagues (and people in general) have similar feelings and thoughts and can get stuck in similar ways. This can be a challenging environment. distrust. this always happens in an atmosphere of serenity. why they behave the way they do. Through the matrix. and soon they’re able to talk about issues that had seemed hopelessly stuck. they can pivot from nonacceptance and fusion to values and committed action. Being more open to themselves and to their colleagues helps bring participants closer together. predictions. people become better able to flexibly take perspective and experientially contact self-as-context. people visibly recognize that they have a choice to act in accordance with their values. Communication problems. as consultants are often called in only after difficulties have become long-standing. Remarkably. and. Early in the process. though this isn’t common in organizational settings. frustrations remained unspoken. a sign that they’re taking a different perspective on the mind’s workings. A Team Negotiating Changes I was called to give a one-day workshop for a troubled team that worked with underprivileged children. The matrix ignites the power of the ACT processes and allows team members to quickly learn hexaflex skills without the trainer having to mention theose skills by name. by the end of a workshop. ACT books invariably advise clinicians to instigate experience rather than talk theory. using the matrix might help you develop your ACT skills much more easily. and tensions ran high. participants are often looking at moving toward their values in areas beyond their professional life. This had helped some. Gossip was sapping morale. team members start making jokes about their own thoughts. In short. In fact. you can just let people experience what it can do for them. you don’t have to talk about it at all. both Chrissie and Bart participated in the workshop. I’ll discuss a couple of case examples that illustrate the versatility of the matrix in organizational settings. Three major issues remained unresolved. Because of the way the matrix is designed. but the team was still in crisis. which in turn has a positive impact on their functioning in the workplace. and Bart knew this was likely. Nonetheless. Over the past year. had the capacity to implement the sweeping changes the team needed. the new team coordinator. Chrissie and Bart. They start looking at how to do more toward moves in their personal life. The situation was acute. In Practice In this section. wasn’t sure that two members. people learn how they can focus on what’s important to them and act upon it while taking all these pesky emotions and thoughts with them. if you’re only just starting to work with ACT. conflicts were left unresolved. This is how the team’s objectives had been phrased: 223 . He told me he’d fired Chrissie on the eve of the workshop and was set on firing Bart the next day.In Business: The Matrix for Team Building and Professional Stress Soon enough. Jan. One of the rewarding consequences of working with this model is seeing that. the team had undergone extensive coaching. He wanted them to stop thinking as individuals and start thinking as a team—something they’d never done before. with the arrival of a new regional coordinator. We want more openness and closeness toward each other. saying. What is your mental experience in that moment?” Next we looked at how the chatter of the mind makes it 224 . I invited them to hold it and imagine what the candy bar might taste like. I gave everyone a candy bar that. “Imagine you walk into the office on a rainy morning and your colleague says ‘Good morning’ in a curter way than usual. I talked about how we can have a very clear image of a five-senses experience in our minds. the policy had changed. This team was undergoing profound changes. The team’s new goals now included teaching the children specific skills to help them deal with particular challenges they faced. The Workshop I started off by telling the group that what they wanted to do with me is against human nature: we don’t like to be vulnerable and feel the associated anxiety.The ACT Matrix We have judgments toward each other that stand in the way of good collaboration. I explained that this was one of the important points of view that we’d be discussing that day. it can differ from the actual five-senses experience. I then shifted to the theme of the day. It had previously been tasked with structuring leisure activities for underprivileged children. After inviting them to taste the candy bar. Now. Then I started exploring the five- senses versus mental experience axis. but we don’t dare express them because we don’t want any conflicts. but that regardless of what that image is. with respect for everyone’s abilities and personality. tasted the same as a very well-known one. Jan’s expectations were for team members to be open with one another and for the team to become tighter. Then I told them that it actually tasted like the well-known candy bar and invited them to notice what their mind did with that. and team members had been recruited on that basis. though it looked different. We want to find a way to implement the new policy together. The team was now responsible for identifying each child’s specific needs and providing the appropriate skills training. The mind will always color the experience and add a running commentary. we came back to the matrix and worked the right side of the toward-away axis. What would you want the teenagers and parents to say about you?” and “Imagine you’re leaving to go home. For a couple of days he gorges on blueberries while his friend hunkers. I asked them not to think of apple pie with ice cream. how she felt about the team. using Kelly Wilson’s story of the blueberry bush (Wilson & DuFrene. Though Chrissie had been fired. Next we took some time to notice how the mind constantly judges things and people around us. she wanted to say that she didn’t blame the team or feel frustration toward them. in a very vulnerable. Then. She said she was okay with being laid off after more than twenty years in the organization. hungry and scared. Clearly. particularly other people’s behavior. Two prehistoric men venture out on the savanna looking for blueberries. to help the group see how thoughts are not as easily controlled as we might think. in their cave. One thinks every blueberry bush he sees is a bear and keeps retreating to the cave they share. I put the following two questions to the team: “Imagine that your community work suddenly came to an end. On the third day. The other knows no fear and boldly makes his way toward every seeming bush. I then gave the group some insight on how the mind works. Despite the fact that she didn’t feel others respected her personality or abilities. She said she knew she didn’t have what was required in the new context. What would you hope they’d say about you?” Next we looked at the top quadrant of their matrix and the actions they already did to move toward these values in the team. … We humans are probably the descendants of the worried and cautious caveman. We started listing the values that were important to participants as a team and as individuals. 225 . it was good for her and the team that she participated in the workshop. Laying this out seemed to allow Chrissie to explain. At this point. but on your way you overhear your colleagues talking about how you participated today.In Business: The Matrix for Team Building and Professional Stress virtually impossible to perceive anything as a pure five-senses experience. the individual coaching she had received helped Chrissie express herself. nonaccusing way and for the first time. It made working together during her notice period easier for both her and the team. who went hungry but survived. it turns out one of those bushes actually is a bear. 2009). That’s how the mind works. And whereas in the morning the team had barely responded to Chrissie announcing her termination. how they felt upon seeing the list they’d created. how can you be more open toward your colleagues with all of these thoughts and feelings toward each other?” At that point. They used the matrix to give one another feedback in a 226 . and reacts to them. I asked everyone to fill in their own matrix and choose one action they would commit to doing to move closer to the team. the sheet of feeling covers me and I realize with tears of joy that I’m happy to be alive. so I asked them to look at the matrix on the whiteboard and share. Finally. They hadn’t realized that they were already doing what they wanted to achieve. We also summed up the feelings and thoughts they noticed when they engaged in away moves. I asked them to take a minute to think about this question: “If what you want is an open atmosphere. Bart didn’t get fired. However. they were already sharing fundamental things about themselves in the early stages of the workshop. the group went quiet.The ACT Matrix Moving to the left side of the matrix. I suggested that the chosen action be about something important to them that they weren’t acting upon.’ On behalf of our team. by the end of the day they could tell her how they’d appreciated her participation and empathically reflect how hard the day must have been for her. gets hooked by them. I invited them to notice the judgments about one another that showed up and to see how they could respond with a values-driven toward move. and importantly for a team that wanted to create openness. everyone shared their matrix and committed action with the group. I want to end this magical day with the following philosophical words: ‘When my senses fall asleep. Afterward. I received a message from Jan: “After that team session. I asked the group what they could see themselves doing as a team and as individuals that moved them away from their values. thank you Annick. He and Jan had a long talk the day after the workshop. They even told Jan that the organization needed to take good care of Chrissie during her notice period. The conclusion was that they weren’t alone in how they felt— that everybody has these kinds of thoughts and feelings. if they were willing.” I’m sharing his message to illustrate how meaningful just one day of working with the matrix can be. The openness experienced in that moment was very powerful and brought everyone closer together. The Aftereffects That evening after the workshop. The school serves a population of disadvantaged teenagers. and the kids often hang around in the street and get involved in illegal activities.In Business: The Matrix for Team Building and Professional Stress values-driven way. His commitment to doing so allowed Jan to keep him on. After some discussion. He could also admit to himself and to Jan that he needed to acquire new skills if he wanted to stay. Truancy is rife. For the first time. occurring in three-hour sessions spread over three weeks. the principal of a school contacted me to ask if I could set up a training course for teachers to increase their motivation and decrease their stress. Before the workshop. 227 . A few weeks after the workshop. and if they had tried. Teachers Stuck in Severe Stress In the second scenario. They struggled with questions like “What am I doing in this job?” “Should I go to the trouble of preparing anything when it’s not appreciated anyway?” and “How can I manage this?” along with thoughts like I prepare so much. but that they didn’t like this behavior. The matrix also helped them stay in the present moment and in contact with each other instead of getting hooked by everything that went on in their minds. but I don’t seem to find time for my personal life anymore. They express themselves differently and have different opinions about education and life than those of most native Dutch students. the person apologized and worked to change his behavior. all presenting with high levels of stress. Jan also made some changes in the team and assigned Bart to a new position within the team where he could best use his abilities. none of the team members would have even considered doing that. a heated argument probably would have broken out immediately. Some of the teachers were embroiled in conflict with a colleague and wanted to be able to handle it better. Six teachers took part in the training. we settled on nine hours of teacher training. and one of them had all the symptoms of severe burnout. Bart could speak openly about what he’d felt during this difficult time of change and how he really wanted to stay on the team. The rest of the team responded in a way that helped the person see that he was appreciated. The students come from poor homes and different cultures and often don’t speak Dutch well. Jan told me that during a meeting someone in the team had reverted to the old habit of communicating without taking the feelings of other team members into consideration. Instead. or memories that show up and have a quality that. emotions. We talked about how we humans can easily lose sight of what matters to us when we’re hooked by our thoughts and emotions and struggle to avoid them. starting with what’s important. I immediately thought of using the matrix. they had started using the matrix.The ACT Matrix Because this intervention wouldn’t be lengthy. and as in the workshop described above. but also in other difficult areas of their lives. we tend to get violently pulled away from the present moment and into actions that are rarely those the person we 228 . but this also usually means we’re moving further away from ourselves and what matters to us. we started working on discriminating five-senses experience versus “living in your head. it’s natural to want to move away from what’s bothering us. and throughout the session we regularly paused to notice what showed up for participants around our work in the moment—what thoughts and feelings they were experiencing. I explained that hooks are thoughts. I ended the session by explaining that the purpose of the matrix is to allow us to notice what we’re doing so we can choose if we want to shift our focus or not. Next we looked at the toward and away axis. Session 1 To begin. I set up the matrix on a whiteboard. Session 2 I started the second session by going over the matrix again and having participants fill it in as a group. making predictions. when we bite. In this session I also invited participants to become aware of their level of engagement toward this training: Did they do their noticing homework? Had they started applying the suggestions in daily life? As it turned out. Next we worked on defusion using the concept of hooks.” I took some time to do exercises that would help participants notice how the mind works. Then I invited participants to notice their toward and away moves and to practice sorting five-senses and mental experience over the next week. I took quite a bit of time to work on the process of creative hopelessness. In the moment. We looked for examples of judging. and so on. and not only in school. which only added to her stress. Looking at her matrix. She resolved to make a doctor’s appointment and seek help. she clearly identified her hook. and as such grossly underqualified to deliver this intervention. which she identified as important. She realized she couldn’t go on like this.In Business: The Matrix for Team Building and Professional Stress want to be would choose. We also practiced some expansion strategies as a way to help make room for feelings of stress and to enhance the ability to notice what’s important in stressful situations. much less claim expertise in ACT. The Aftereffects I received spontaneous e-mails from four of the six participants saying that. Reflections on Your Matrix as an ACT Trainer The purpose of ACT is to increase psychological flexibility. and were applying these tools in many different situations. she bit. I may start to give wordy and theoretical-sounding explanations to move away from the shame and thoughts of being inadequate. but she also became irritable and often reacted in ways she regretted. Demonstrating my own away moves. as a result of the workshop. I said that when this hook shows up. As a trainer. I shared that one of my hooks is that I am only a social worker. Session 3 In our final session we used the matrix to look at participants’ experiences over the past week. you want to respond as effectively as possible to signs of psychological inflexibility. she tried to force herself to carry on. Then she made a choice not to bite and to choose self-care. The teacher who was suffering from burnout dearly wanted to continue teaching. were moving closer to their values. they avoided less. When it showed up. I then invited participants to identify their hooks in their professional context and what they did next. One of her hooks was that she couldn’t let her students down. One way this is done is by 229 . whether in clients or systems. were more focused on what worked for them. but every time her hook showed up. common thoughts include I don’t know who these people will be. Here are a 230 . Some of them might only get you hooked and restrict your options. to look at where you stand in your matrix. helping you better prepare for the task ahead. As an ACT trainer. Make time. Notice what you do next. What would you love to hear them say about you and about how the day went? What could you do to move toward being a trainer who would make them say that? What Do You Want to Move Away From? Next. How Can You Cultivate Toward Moves? Some of those difficult thoughts and concerns can be useful. How will they respond? Will I be able to manage their reactions? Will I have enough time to do what I planned to? Most revolve around Will I succeed? and Am I good enough? You might even have had the thought that teaching people ACT means you shouldn’t be nervous—that you of all people should know how to handle your feelings effectively. It will also help you get through the rough moments of participant resistance. Based on conversations with other ACT trainers. Other common ideas are that the matrix is just too simple and that people won’t like it.The ACT Matrix modeling psychological flexibility. the more able you’ll be to keep your focus on that during a workshop. when you’re able to notice what’s going on inside you and respond in a flexible way. Imagine you can hear participants chatting together in the training room at the end of the day. the matrix can be a precious tool. and so on. it stimulates the flexibility of the group you’re working with. What Kind of Trainer Do You Want to Be? Start at the bottom right of your matrix. look at what you may not want to think or feel. negative feedback. Here again. with the question “Who do I want to be as an ACT trainer?” The more openheartedly you approach this question and the more you stay in contact with it. Working with participants who feel stressed or tense can be stressful for the trainer too. aside from your formal preparation for trainings. See if you can notice and stay in touch with what’s going on in your mind and body. such as What if…? or Will I be able to…? I invite it to take a seat and wait for the others to arrive. and let go of automatic away moves. with red velvet curtains and chairs. Aisling Curtin suggests going into the bathroom before the workshop starts and taking some time for yourself. I’ve noticed that every time a new pesky thought pops up. by the time it takes its seat the other thoughts have already disappeared. Embracing Your Nerves Gently make room for the discomfort you’ll inevitably feel. I am the audience. This helps me every time. I imagine a theater in my mind. faster breathing. Before the Workshop Can you stay in the moment while preparing? Can you focus on the task at hand. On the stage stands a row of empty chairs with golden armrests and red velvet cushions. or is your mind predicting all kinds of stuff or reminding you how the previous workshop went? In conversation. psychologist Rob Archer has pointed out how when we find a task too stressful or boring. Unhooking If you get hooked and are pulled to away moves. or a dry mouth. 231 . such as butterflies in your stomach. Nurture compassion for the stress and distress that will inevitably show up. Here’s an exercise I came up with that works for me.In Business: The Matrix for Team Building and Professional Stress couple of suggestions for using painful inner experiencing to cultivate toward moves. trembling or sweaty hands. Rest your hands on your chest and tummy and breathe gently into these spots. What Are Your Away Moves? Away moves may show up as you’re preparing or while you’re conducting workshops. welcoming any nervous feelings in that moment. Every time I’m aware of a thought popping into my mind. use your defusion skills to unhook. they will only increase your nervousness and cause more discomfort. and so on. getting annoyed. talk to colleagues. you could share your thoughts and feelings in the moment and check in with participants. If people can’t experience that what they’re doing causes more pain and is unworkable for moving toward what’s important. you might want to notice people going quiet on you. If you notice people resisting or moving away from you or the workshop content. asking you where this is going. how will they be motivated to change? As a trainer. telling you you’re going too fast. Notice your own away moves. read a newspaper. the idea of letting go of your preparation may be scary. They might signal how you’re feeling about what you’re working on. and so on. people typically aren’t interested in theories or concepts. the more you can respond flexibly and not let your inner experiencing determine how you conduct your training. During the Workshop When a workshop starts. go on Facebook or Twitter.The ACT Matrix we might get up to get some coffee. you could lose your participants for the rest of the workshop. asking why they should do an exercise. especially when it comes to creative hopelessness. The ACT perspective differs from what most people are used to. you may ask for a level of openness that they aren’t ready for. Another risk is excessive preoccupation with the schedule. and this can backfire. This might make it harder to train how to handle awkward feelings and thoughts in a more flexible way. and it takes some time to grasp it. This may tempt you to explain things rather than propose an exercise. Working in Organizational Settings In organizational settings. Their objectives are often clearly defined. and they want to see 232 . The more you can stay in touch with all of your feelings and thoughts. Yet being too occupied with your notes or a preconceived plan could prevent you from noticing what’s going on in the group and the way participants respond. Recognizing these feelings and practicing acceptance and contact with the present moment as you’re preparing can make it easier to receive them when they show up during a workshop. As a result. If you go too quickly. In this way. but by the end of a workshop collaboration is typically strengthened and a stronger group identity emerges. The matrix can help trainers stay flexible and identify where in their matrix they are at any given moment. Models are only of interest to the extent that they work. It can help build team purpose and effectiveness. and reinforce flexibility. Although the matrix is pragmatic. Conclusion I’ve found the matrix to be an ideal tool for interventions in organizations for many reasons: It can help set ground rules for conducting an effective meeting. which makes teams stronger and tighter. rather than submitting to company or management values and imperatives. In such contexts. It’s an effective tool for conflict resolution. the matrix is a compact. instigate. 233 . With the matrix. Participants have gained psychological flexibility as individuals and as a group. it allows for a firm focus on what’s important and thus injects deep meaning into interventions. Based as it is on normal functioning. it can quickly overcome the distrust that interventions focused on making employees fit the mold can rightly elicit. It quickly promotes psychological flexibility and itself is flexible enough that it can be modified to fit the contexts and situations in the training room and in people’s lives. helping them model. powerful tool that allows for adaptable work with the ACT processes.In Business: The Matrix for Team Building and Professional Stress results. not only do people learn how to deal with stress and conflicts. This focus on values also means that matrix interventions are ultimately in the service of each and every participant moving toward what’s important individually. ACT is based around six processes of inflexibility versus flexibility. Pragmatism is built-in. Laying these processes out in detail may try the tolerance of people looking for quick and concrete help. it allows for a quick setting up of a perspective in which all people can recognize that their inner experience and what they don’t want to feel or think is part of their common humanity. It can help manage major changes in an organization. and DuFrene. London: Routledge. (2006). Bond. It can assist in giving effective feedback within teams. In my relatively short time using the matrix in organizational settings. Acceptance and commitment therapy (ACT) in the workplace. Still. (2009). References Flaxman. A. It can help individuals and teams be more effective and values driven. S. P. 377–402). W. W. to ensure the new skills are practiced.). F. Acceptance and mindfulness at work: Applying acceptance and commitment therapy and relational frame theory to organizational behavior management.The ACT Matrix It can aid in identifying possible sources of stress and working out what to do about them. E.. G.. I’ve seen people grow after very short interventions. & Bond. Burlington MA: Elsevier Academic Press. Hayes. This list is far from exhaustive. Baer (Ed. K. perhaps by readers of this chapter. Wilson. (2006). F.. and I have no doubt broader uses for the matrix will be derived. & Barnes-Holmes. I recommend conducting a couple of coaching or refresher sessions to keep the process of change alive. Mindfulness-based treatment approaches: Clinician’s guide to evidence base and applications (pp. CA: New Harbinger.. T. C. and to troubleshoot any potential setbacks. D. Oakland. 234 . In R. Mindfulness for two: An acceptance and commitment therapy approach to mindfulness in psychotherapy. I’ll quickly review the origins of acceptance and commitment training and therapy and then discuss how acceptance and commitment therapy and especially the matrix are directly connected to the evolutionary process. Evolution. This is like . It looks at a human behavior (action) in context. touch on the evolution of language and ACT’s approach to the problems language can cause. Functional Contextualism ACT is based on functional contextualism. I’ll quickly run through functional contextualism and relational frame theory. and land right back on ACT and the matrix. take a brief look at the social ramifications of these processes and Elinor Ostrom’s eight core design principles for optimal group functioning. a scientific point of view that seeks to increase the frequency and variety of behaviors that work to improve the human condition. and Improving Work-Group Functioning with Ostrom’s Eight Design Principles Kevin Polk In this chapter.CH A P T ER 14 The Matrix. and in that regard the whole human is the action. To do so. Organisms live in a Newtonian physical world. improve the human condition. While Newton was concerned with planets and rocks. mechanistic removal of choice can limit the human condition. it is the whole human behaving. Darwin saw that three processes came together to shape the evolution of any living thing: variability 236 . I had no choice but to honk my horn and give him the finger!” Said another way. it’s the whole human talking to us. which means the other driver has taken away the person’s choice of emotion. which has its roots in Newtonian physics. you see one whole human being walking down the street. scope (across contexts like home. His equations led to the industrial revolution and helped shape our understanding of the universe. and depth (psychologically. So the person walking down the street might pause and talk to us. Darwin was writing about how living things arrived at both their physical form and their behaviors in a given environment. Functional contextualism is more in line with the approach of another great thinker: Charles Darwin. Functional contextualism is most often contrasted with mechanism. the other driver caused the anger. Using Newton’s equations. head to toe. Also. we strive to predict and influence behavior with precision (with the fewest symbols). To help lessen human suffering. sociologically. and planets. to the extent that language like the following has become common: “That other driver really made me angry. and anthropologically). school. When pressed. almost everyone would agree that there was a choice of whether to honk the horn or not and whether to give the finger or not. Newton’s ideas have been very fruitful for humans. and enhance evolution. You don’t see a body and a mind walking down the street. not a mind plus a body. when a human uses language. this artificial. yet how their behaviors and physical forms transform through the ages can’t be predicted through Newtonian physics. In the greater scheme of things. and work). cars. we can predict with great accuracy the movement of objects like bicycles. The combination of physical form and behaviors in the environment could have life-and-death consequences for a single organism or a species. It was only natural that the predictability within Newtonian physics found its way into explanations of human behavior. which then caused the behaviors of horn honking and gesturing. from a functional contextual perspective.The ACT Matrix seeing someone walking (action) down the street (context). But many would still maintain that the anger was caused by the other driver. You could show them pictures of trees and bushes. RFT is different than other accounts of language in that it looks at the function of words. and they could sort the pictures into two piles: trees and bushes. there are still a few pictures that don’t quite fit in either category. It uses the functional contextual worldview of finding workable behaviors in context that are then passed on through generations. RFT isn’t concerned with the accuracy of categorizing things like trees. Evolution. Don’t think this really happens? Take a look at a duckbill platypus. However. most people might agree on what a tree looks like and what a bush looks like. vegetables. For example. or noncausal. The notion is that while mechanistic thinking tends to limit psychological flexibility. animals. terms. or perhaps just better success at breeding). The question becomes “Is this languaging (maybe about trees and bushes) working to move us in the direction we want to go in life?” Said on an individual level. not some mind-body split. and heritability (in which successful changes in physical form and behavior are passed to future generations).The Matrix. bushes.g.. and Improving Work-Group Functioning (both physical form and behavior). functional contextual thinking increases. not the accuracy of what words represent. Darwinian thinking currently doesn’t have much of a foothold in the discussion. and so on. the mind being represented by cogs and wheels spinning inside the skull). or a bush that looks like a tree. the question is “Is my languaging 237 . Scientists have argued for ages about perfect trees and perfect bushes. Relational Frame Theory Relational frame theory (RFT) is a theory of how humans learn language and cognition. consequences (perhaps life- and- death. It looks at the function of words and language. Relational frame theory and ACT seek to describe and influence human behavior in Darwinian. While causational and mechanistic Newtonian thinking has long informed descriptions of the function of human language and cognition (e. Then the plant scientists get involved and provide technical language to sort out trees and bushes. The whole human participates in languaging. The sorting works almost all the time—until you find a picture of a tree that looks like a bush. Then one day “mom” showed up in your mental experiencing. and smells of mom) is combined with your internal experiencing and related to a sound. Sadly. Let’s look at another example. RFT gives a behavioral account of language rather than using made-up mechanistic terms for different parts of the mind. If I tell you that A = B and B = C. and then another thing. Business and political leaders often 238 . You know that A = C. or my religion versus your religion. We’ve sent astronauts to the moon by deriving new relations. we instead ask.” and she gave you a broad smile and a big hug. Sensory information from the world (for example. She was warm and fuzzy and gave you nurturing stuff. you know something more. have engaged in thought experiments to derive great things using this ability. that little trick is called derived relational responding. Great scientists.” Instead. mass murderers have concocted imaginary worlds to such an extent they’ve killed many people. and making sense was rewarding. In RFT terms this is called relational framing. sights. Then one day you saw her and uttered “mom. and then putting those things together into further understanding.The ACT Matrix moving me toward who or what is important to me?” On a societal level it might be “Is this languaging moving us toward peace or destruction?” Why is categorization versus functioning so important? Because people get into huge “I’m right and you’re wrong” arguments about categories like trees versus bushes. sounds. With the rewards your mom was giving you for uttering the sound “mom. While language is obviously very useful. In brief. “Is this languaging working to move us toward our values?” We replace “I’m right and you’re wrong” with the question “Is this working?” It is far beyond the scope of this chapter to explain RFT in detail. From a functioning view of language. and it’s huge. We humans are forever learning one thing. In RFT. and you get rewarded for that relating. such as “the language module” or “short-term memory module. such as Einstein. At that moment you had put it together: saying “mom” made sense. People kept uttering the sound “mom” when she was around. Pretty soon you said “mom” a lot in her presence—and got more smiles and hugs. RFT might sound like this: As an infant you saw your mother a lot. people have become so good at taking worldly experiencing and transforming it to internal sounds and symbols (language) that it’s easy to live in an imaginary world inside the mental experiencing.” you began to get hooked on language. shrubs. it looks like one person behaving. there’s always more than one of you in the room. Said another way. predators. For example. rocks. One was to help protect us and others. Thinking and feeling are of course related. one part of the mind causes another part of the mind. and the whole human being behaves. as if thinking were a cue ball striking the emotion ball and sending it in a predictable emotional direction. Language Is Social Language probably evolved in humans for social functions. it’s done from the “me” point of view.” Once the “me” showed up as language. This artificial language-based separation of the self into at least two parts is important because of Newtonian and Darwinian thinking.” From an outsider’s perspective. If we apply Newtonian thinking. However. there is just one of each of us. and Improving Work-Group Functioning seem to be living inside the mind and not paying attention to real-world facts. The trick is to lift people out of excessive mental experiencing when such thinking is becoming too restricting and harmful. the less psychologically flexible the 239 . but relation is not causation.The Matrix. the sentence “How you think determines how you feel” applies Newtonian determinism to the artificial. Since language is great (to a point) for symbolically dividing things up into categories. even when you’re by yourself. want to hang out tonight?” While languaging is social. the separate selves make sense thanks to social language. For example. “Watch out!” Another was to make babies. From inside the skin. by saying stuff like “Hey good-looking. most people would say that thinking I’m a failure causes sadness or some similar emotion. The more a person believes that thinking one thing automatically leads to a certain set of behaviors. people could talk to others (me to you) and to themselves (me to me). by yelling. eventually the self was divided up into the categories of “me” and “mind. But in reality. that’s just silly. And people often suffer horrible pain as they struggle to avoid imaginary demons in the mind. as in “me over here and you over there. and so on. so one part of me talks to another part of me. From the perspective of your own language. such as trees. language- based separation of self. in the outer world. to use language I need someone else to talk to. for example. Evolution. there are people out there who might get pleasure from that thought. As this categorization and organization process expands to determine how neighborhoods. allowing us to get out of our heads and experience the worldly consequences of our actions. much faster than the evolution of most organisms. ACT and the matrix seek to reverse the inflexibility of such languaging and increase people’s adaptive behaviors. Finally. Language is infinitely variable. consequences. evolution needs three ingredients: variability. probably because we get positively reinforced for things making sense. We are polluting our environment (the stuff our bodies live within) at an extinctive rate because language allows us to create polluting machines of great size (factories) or in great numbers (cars). We would want symbols that allow us to derive more behaviors (variability) for continued human existence. it is also possible to change language for the better quite quickly. Humans just love sorting things into the right categories. However. cities. states. according to Darwin. 240 . the evolution of language is much. have created really helpful stuff for humanity and really hurtful stuff for humanity. Therefore. we need symbols that are easily passed to future generations. People get into heated verbal spats (and sometimes physical fights) about who’s right and who’s wrong regarding how things are categorized and organized. Evolution and Language Recall that. we humans are at risk for lots of fights over who’s right and who’s wrong about how things should be categorized and organized. Human Conflict A big part of language is classifying things in the “right” category. it has consequences (sometimes life-and-death consequences). consequences. being “right” about how things are organized and categorized becomes very important. and heritability. and it’s easily passed down through generations. towns. Yet because language is so powerful and fast. humans. given symbols that can exert a positive influence on variability. and heritability. we now have enough nuclear weapons to destroy several earths. In just a few hundred years.The ACT Matrix person becomes. and nations are organized. For example. using language. What’s the answer? To use the title of a popular ACT book (Hayes. People become so fused with their language that they forget language represents the world but isn’t the actual world. 2005). values. or organizing behavior is right. stop relying on the behavioral consequences you think are happening and instead pay closer attention to the real-world consequences you can experience through your five senses. We also look outward. where there’s a healthier mix of sensory and mental experiencing. they lose the ability to choose when to discontinue behaviors and derive new behaviors that might work better. defusion. it seems that the stuff going on inside our heads is the world. self-as-context. To counteract this loss of psychological flexibility. to those who are literally referred to as like- minded individuals—those who share our views and biases and provide reassurance that we’re right. language can get us stuck in arguing over categories while the world is burning. and committed action. and noticing the difference between how it feels to move toward what’s important and how it feels to move away from unpleasant internal experiencing. How we go about getting out of the mind in this way is the process stuff of ACT. 241 . Acceptance and Commitment Training and Therapy ACT is based on the notion that people can get trapped in the mind to such an extent that they lose psychological flexibility. get out of your mind and into your life! Said another way. up toward the center. Evolution. From the matrix point of view. ACT proposes several processes that can be worked on one at a time or together to increase psychological flexibility: acceptance. When we’re fused with language. categorizing. reducing them to two discrimination tasks: noticing the difference between sensory and mental experiencing. and Improving Work-Group Functioning To put this succinctly. present-moment awareness. We instead look inward for reassurance that our thinking. regardless of real-world evidence. down in mental experiencing. The matrix is a simplification of these processes. That is. Then we aren’t open to experiencing the real-world consequences of the behavior called language.The Matrix. it’s like being lifted from the lower half of the diagram. get transformed into sounds— language—within a person. such as fear. pain. We can find some of those feelings on our own. and we’re drawn to the good feelings we get with others. Thoughts (internal sounds) and images show up and we have emotions.The ACT Matrix ACT is a way of interacting with others to lessen the bonds of language and get people more in touch with real-world consequences. and happiness. Recall the basic idea of RFT: that reactions to the physical world. Life inside these conversations requires little contact with the physical world. ACT is designed to get us out of our heads and back to noticing the consequences of behaviors. but we can find more with other people. But how do we go about engaging people in a process that lifts them out of the mind and into noticing consequences? Acceptance and commitment therapy was designed to be one way of influencing people away from the stuckness of language and back into noticing what’s happening in the moment. we can think about events in the future and have emotions. And because all of that stuff is represented by sounds and such inside our minds. and love. both old and new—hence the title of Steven Hayes’s book Get Out of Your Mind and Into Your Life (2005). We are a social species. happiness. pain. and about the wider world and ourselves. One emotion that can show up independent of an environmental reason is fear. love. we can simply recall events from the past and then have the emotions associated with those events. Experience shows that simply teaching people about the problem isn’t enough. Within “me to me” conversations. this gives us the ability to have conversations with others about fear. humans want to move away from fear. the group. and entirely another to influence people out of their heads and toward being engaged with consequences. Likewise. they just don’t take precedence over consequences perceived through our senses. Yet it’s one thing to talk about people being stuck in their heads and losing contact with consequences. In general. ACT is an 242 . happiness. we can escape from danger and pain or move toward joy and love. Mental consequences are still important. and procreation. We can practically live our lives inside them. Since language is social. as when one thinks of a tiger and fear shows up. That makes evolutionary sense. In more evolutionary terms. moving away from real-world fear keeps a person alive for the self. and love. In addition. getting stuck in your head is a problem because it removes you from contact with consequences. However. humans want to move toward emotions like joy. but they might also end up somewhere they 243 . they zigzag in no particular direction. psychological flexibility is being increased in the context of a behaviorally organizing reference called values. Therefore. values provide a reference point for adjusting behaviors to reach a point in the distance. these are behind us and can’t provide a reference point for organizing our behaviors. and this psychological distancing is synonymous with psychological flexibility. Therefore. Psychological flexibility increases the probability that the person doing the discrimination tasks will derive new behaviors. and noticing the difference between how it feels to move toward values and how it feels to move away from unwanted mental experiencing. Evolution. and evolution science into one package designed to influence people by engaging them in a process rather than just sending information their way. and Improving Work-Group Functioning intervention that combines functional contextualism. Away moves are not organizing because they are short-term fixes and thus cannot provide direction. This book is about one succinct way of going about engaging and influencing: the matrix diagram and the words used with it. Like a tree on the horizon. increasing the probability that people would derive new responses to their trauma memories. Driven by functional contextualism. and as a result. the matrix was designed to increase psychological flexibility by engaging people in two discrimination (sorting) tasks: noticing the difference between sensory and mental experiencing. How the Matrix Works The matrix was originally conceived as a game in which people would sort trauma memories into categories so that defusion would occur.The Matrix. getting them out of their mind and paying closer attention to the consequences of languaging. They may indeed avoid being stung. ACT strives to find succinct language that engages and influences people. Values provide psychological points of reference for testing the workability of behaviors. Notice that the toward and away discrimination task implicitly includes values. A popular ACT metaphor is to imagine you’re running away from a swarm of angry bees. relational frame theory. Some psychological distancing (defusion) is required to do both of these discrimination tasks. People tend to look over their shoulder to see how close the bees are. Metaphorically. but that same chitchat might not work at all while sitting at a funeral. the group can produce much more food. further multiplying the effect of individuals. The workability of toward behaviors is also subject to context. language allows humans to recall a story of bees or a tiger to such an extent that a human can avoid imaginary bees and tigers while sitting in the living room. Humans have turned this ability to the task of creating machines that could do much of the work of producing food. another might plant seeds. humans are very social animals. is for humans to notice the consequences of their behavior while in context. another might plow. communities. However. For example. Much of human existence is dependent on working together with other humans to solve the problems of food and safety. given that we end up staying home to avoid these dangers. even worse. and that requires being open to both sensory and mental inputs while engaging in both toward and away behaviors. However. and so on. One need not look too closely to notice that humans cluster together in groups. an away behavior can save one’s life. and working together. For example. Community I’ve been focusing on an individual’s behaviors in the context of the individual’s values. The key. No single person is responsible for the entire crop. and so on. a tiger). A small group cooperating to produce food is an example of a group sharing common resources—land and water—for the survival of the 244 .The ACT Matrix don’t want to be. And being able to analyze the consequences of a behavior requires knowing one’s values. one person might clear a field of trees and stumps. Avoiding fear often doesn’t get you where you want to go in life. Those machines led to more machines. and cities—and for good reason. engaging in chitchat with a potential lover might be very workable on a sunny day in the park. This probably isn’t very functional from an evolutionary viewpoint. For example. Both toward and away behaviors can be very functional depending on the context. Humans long ago learned how to cooperate and divide labor into small parts. in terms of evolution. with the small parts coming together as a whole. in the presence of danger (like the bees or. central government was necessary to manage common resources like land and water. it needs to be flexible in developing new behaviors as the context the group is living within changes. the dominant thinking was that a large. Then along came Nobel Prize–winning economist Elinor Ostrom. She found that groups who were successful at managing the commons had some behaviors in common (Ostrom. For the group to continue to prosper. contrary to popular late twentieth-century economic thinking. Managing that balance is of vital importance to human adaptation and has been the topic of countless books and articles. 1990). Evolution. Ostrom’s Eight Core Design Principles After studying successful and not-so-successful groups around the world. Ostrom described eight core design features for successful group management of the commons. much of the group will always be invested in keeping the sharing behaviors the same. Collaborative decision making in the group 245 . rather than adapting. Proportional costs and benefits 3.” as she termed them. Shared identity or purpose 2. Indeed. our systems of government are in large part based on balancing between keeping things the same and making changes to adapt.The Matrix. The following are paraphrases of Ostrom’s principles: 1. However. This balance between keeping the common sharing behaviors the same and changing behaviors to adapt is one of the most fundamental conflicts of all human groups. 2011). For many years. her eight design principles have proved to be a functional way of looking at group behavior for a wide variety of social groups (Wilson. In Darwin’s terms. While her observations were of social groups sharing scarce resources such as land and water. since much of life is dependent on keeping things the same (homeostasis). and Improving Work-Group Functioning group. No large central governing body was needed. who found that. the group needs to adapt to the changing environment. small groups could manage “the commons. Small groups were thought to be incapable of such balancing. A system of graduated sanctions such that the punishment fits the crime 7. So how does a group come together and use the behaviors described in these principles to keep things the same when needed but change when required by the context? Anyone who has observed group behavior would recognize that many groups don’t possess these eight design features. 246 . However. What is needed is a way to increase psychological flexibility within individual members of the group and then set the stage for group dynamics where the products of that flexibility can be shared.The ACT Matrix 4. leaving the group incapable of successfully managing the commons in the present and adapting for success in the future. groups can be a context where psychological flexibility is limited by fears that are inherent to being a member of a group.” High group flexibility means group members are at ease to speak their mind. the larger group operates by the same principles While the matrix diagram can function to increase the psychological flexibility of an individual. A trusted system of conflict resolution for cases where gentle reminders don’t work 6. Bureaucratic and individual inflexibility often enter into group dynamics. The study of the fears inherent to group membership is summed up under the term “group flexibility. the smaller group has minimal rights to organize 8. Groups depend on the psychological flexibility of each group member—the ability to notice the consequences of both away and toward behaviors and to adjust behavior to improve group functioning. Monitoring and gentle reminders for people not to cheat the system 5. What is needed is a way of influencing individuals in the group toward flexible group behavior for successful management of the commons in the present while also setting up the group for successful adaptation across the changing contexts of time. When nested in a larger group. It’s interesting how we humans are drawn to groups but at the same time fear being part of a group. When nested in a larger group (such as a state in a country). such as being laughed at or gossiped about. these principles are concerned with increasing the psychological flexibility of the group. low flexibility means they shut up. What behaviors could you do to move toward who or what is important to you? (Answers are written in the upper right.The Matrix. we first do the basic psychological flexibility warm-up (see also chapter 1): 1. anyone will be taking a more “distanced” self-view. using the following questions: 1. What behaviors do you do to move away from or lessen unwanted internal experiencing? (Answers are written in the upper left. Recalling how it feels to move away from unwanted mental experiencing 6. we can take a quick loop around the matrix to help increase psychological flexibility. An exercise in mental experiencing 3.) Notice that by the end of this first loop around the matrix. Who or what is important to you? (Answers are written in the lower right. If we were doing the usual psychological flexibility training.) 4. Recalling how it feels to move toward what’s important 5. An exercise in five-senses experiencing 2. Noticing the difference between how toward moves and away moves feel First Loop Around the Matrix Following the warm-up routine. and Improving Work-Group Functioning Two Loops Around the Matrix To do this work with any type of group. Evolution. because we’re interested in people’s 247 . we would simply do more to increase this distanced view and the chances that the person will learn behaviors that work for valued living.) 2. Noticing the difference between five- senses and mental experiencing 4. Here. What shows up inside you that can get in the way of moving toward who or what is important to you? (Answers are written in the lower left.) 3. ) 248 . and urges that are usually under the surface can be brought out in the open quickly and painlessly. are written in the lower left. 3. the fear of speaking up. In this second loop around the matrix. and almost everyone engages in behaviors to move away from them—behaviors that ultimately don’t work for the group’s shared purpose. Notice the difference between your sensory and mental experiencing of your fellow group members. Look around the room and take in your fellow group members through the appropriate senses.) 8. jealousy. 4. 2.The ACT Matrix behavior within a group. thoughts. such as envy. and their answers. for example. 5. 7. Recall moving toward shared group purposes with this group or some other group you’ve been a member of. What might show up inside each of you that could get in the way of moving toward the shared purpose of the group? (All members participate. and anger. and the results are written in the lower right quadrant. we need to create a level of group flexibility that allows members to speak up and help the group evolve behaviors that help the group. 6. such as seeing and hearing. Almost everyone has these unwanted mental experiences. Now close your eyes and experience your group members in your mental experiencing. Here’s how we might conduct the second loop: 1. Now notice the difference between how it feels to move toward a shared group purpose and how it feels to move away from unwanted internal feelings when part of the group. What is the purpose of this group? (All members talk. feelings. so we make a second loop around the matrix. Second Loop Around the Matrix The second loop around the matrix serves the purpose of getting negative emotions that can show up during group life out in the open. Recall moving away from unwanted feelings that have shown up in this or some other group. Evolution. are written in the upper left. Ostrom’s eight principles. What kind of behaviors can group members do to move toward the shared purpose of the group? (Answers are written in the upper right. the tenth item can take a lot of time as group members come up with individual duties and roles that can contribute to the shared purpose.) 10. 249 . The group can do both loops as often as needed to maintain group functions. What kind of behaviors might you do in the group that would move you away from the mental experiencing in the lower left? (Answers. and Improving Work-Group Functioning 9.The Matrix. and naysaying. not working. The Spoke Diagram Monitoring Collaborative Decision Making 10 10 Polycentric Governance 10 Proportional Benefits and Costs 10 10 0 10 Minimal Recognition of Rights to Organize Graduated Sanction 10 Conflict Resolution 10 Group Identity or Purpose Figure 14. such as gossiping.) Obviously.1. When one or more of the spokes is at less than 10. D. Governing the commons: The evolution of institutions for collective action. and they’ll feel safe in the knowledge that sticky group processes can quickly be addressed with the matrix and spoke diagrams. References Hayes. the approach briefly outlined here increases psychological flexibility and group flexibility by helping the members of a group step back and view their individual functioning within the group from a more distanced perspective. From an evolutionary view.1 has a spoke for each of the principles. Notice that there’s a 0 at the center of the spokes and a 10 at the end of each spoke. The neighborhood project: Using evolution to improve my city. S. Cambridge. forming a rating scale that allows the group to rate functioning on each of the eight spokes. From this perspective. If all are at 10. (2005). So now the group can turn its attention to the other seven spokes. E. Wilson. The bottom spoke. (1990). (with Smith.” is the most important and was addressed during the two loops around the matrix. S.” and those spokes could use some work. CA: New Harbinger. 250 .The ACT Matrix Now let’s take a look at a way in which the group can monitor its functioning according Ostrom’s eight principles. Conclusion From a behavioral and political view. Get out of your mind and into your life: The new acceptance and commitment therapy. this approach increases the variability of behaviors by enhancing psychological flexibility and group flexibility. the group is rolling along. Figure 14. the group is “bumping along. UK: Cambridge University Press. they can learn to be flexible. one block at a time.). It also increases the group’s awareness of the consequences of individual and collective behaviors and provides a ready means of passing along successful group behavior by allowing the group to show other groups how they use the matrix and spoke diagrams. “Group Identity or Purpose. (2011). Oakland. S. learning about each and assessing group functioning on each dimension. New York: Little. Ostrom. Brown and Company. schools. people started coming up with cool new things to do to move toward their values. That reinforcement process drives the viral aspect of the matrix. From the beginning it was clear that after working with the matrix diagram. When we presented it to community groups. and you get a huge rush of reinforcement when it does. communities. Olympic athletics. Once people learn it. It began with people in mental health groups sharing with their family and friends. In that sense. have them sort the answers into the categories. businesses. You too may have the irresistible urge to share the diagram with others. the two lines were being referred to as a virus because many people who learned it were compelled to pass it on to others. you’re looking for your next fix. more workable behaviors. At that point there’s no putting the diagram down. Within weeks after what was then called the grid emerged.CONCLUSION Going Viral Kevin Polk and Benjamin Schoendorff Thus far the matrix has made its way into mental health settings. prisons. there’s just no telling . we soon heard of more people showing the matrix to others. It’s wildly reinforcing to stand or sit in front of other humans. The matrix is also evolutionary. We aren’t kidding—you see the deriving happening in front of you. and we certainly encourage you to do so. ask them just a few easy questions. and see them quickly derive new. they find new places and new ways to present it. Then students who learned the matrix in school shared it with their friends and family. show them a couple of lines. and summer youth camps. By the time this book is published it will have made its way into more settings. classrooms could become places where students and teachers alike engage in cooperative movement toward individual and group aspirations. They teach. Many students and teachers feel stuck. It’s 252 . It’s already in the hands of a few thousand people. With the matrix diagram. Using the matrix in conjunction with Elinor Ostrom’s eight core principles (1990. With the publication of this book. and maybe the matrix can help them find a way out. Team meetings around building and implementing a team matrix could unleash workplace creativity as team members evolve an approach to moving toward what’s important for them and for the team as a whole. the students listen and learn. so its use is unlikely to leave people stuck in conflict. Finally—and you may say we are dreamers—we envision the matrix making its way into society at large. In our opinion. such a change is possible. moving away from trying to force employees to submit to the needs of the business or simply reduce stress.” They simply need to learn a few basic skills for increasing psychological flexibility in the context of who or what is important. It doesn’t require special skills to present the matrix. We also see the matrix moving into the professional sphere and helping workplaces become environments where people can start to choose to move toward who or what is important to them. They’ve been taught that a style of teaching that conforms to the Newtonian perspective is the only way. Introducing the matrix can shift the perspective in the workplace. In this way. The matrix is fundamentally nonjudgmental. see chapter 14) can help classrooms come alive as students become responsible for their own behaviors. We’ve heard that many teachers feel stuck in the role of classroom enforcers. knowing when their behaviors are moving them toward who or what is important to them and when they’re moving away from unwanted feelings and disrupting the learning process. and instead moving toward creating a space in which everyone can flexibly adapt their behaviors to be more in line with who or what they want to move toward. the most crucial place for the matrix to take off is in the education system.The ACT Matrix where the matrix will go. Above all. helping all types of organizations move toward psychological flexibility. the students are to follow the rules of behavior as if they were Newton’s laws. it will be in the hands of thousands more—readers like you who will find new places to present the matrix. Teachers don’t need to be incredibly adept “student whisperers. UK: Cambridge University Press. Governing the commons: The evolution of institutions for collective action. (1990). E. the more psychological flexibility will spread. Let’s give increased psychological flexibility a try and see how it works. In closing. Reference Ostrom. the future of the matrix diagram depends on a very ACT- like question: Are you willing to have some discomfort and make some mistakes while presenting the matrix to others? The more people who can answer yes to that question. Cambridge. that skill level is just a few practice sessions away. With the matrix. 253 . Almost anyone can practice the notes and pauses until it sounds like beautiful music and others can’t resist joining in.Going Viral literally like learning to play a very simple tune on the piano. . Find out more at http://www. is a clinical psychologist who has been a practicing for twenty-three years. Wilson.com. he leads international workshops on integrating ACT and relationshipfocused functional analytic psychotherapy through the use of the matrix. A peer-reviewed ACT trainer. spending close to 20. PhD.onelifellc. Foreword writer Kelly G. and a clinician’s manual based on the matrix diagram. . and was one of the authors of the landmark Acceptance and Commitment Therapy. Polk.000 hours studying the philosophy and theory behind ACT.ipc-cpi. and learning and designing ACT interventions.com. Editor Benjamin Schoendorff. He is a peer-reviewed ACT trainer who is passionate about teaching others how to use the matrix to increase psychological flexibility and valued living. He is the author of two French language books. PhD. MSc. He is a central figure in ACT. Find out more at http://www.Editor Kevin L. You can find out more at http://www. Wilson is among the most sought-after ACT trainers. primarily helping veterans and others with troubling trauma memories. is a clinical psychologist with a passion for disseminating contextual psychotherapies.drkevinpolk. His popular experiential workshops touch thousands of clinicians and students each year. an ACT self-help book. MSc. is associate professor of psychology at the University of Mississippi.com. For the past eight years he has dedicated himself to the study of acceptance and commitment therapy (ACT). . 87–89. 184 anger. comprehensive distancing and. 159 assessment: addiction recovery. 79–80. 67–69 Acceptance and Action Questionnaire-2 (AAQ-2). 28–29. integrating with the matrix. values clarification in. verbal. 96 acceptance and commitment therapy (ACT). 84. challenges developed for. recognition of. Egide. 229–232. self-as-context in. 85. client group for. 9. training people to deliver. 48–52. present-moment awareness in. 141–142. workability. 218–219 anxiety attacks. 78–79. in vivo exposure used in. modeling by trainers of. 21–22. standards of practice. task shifting in.Index A acceptance: chronic pain and. 43. moving toward as. 94–106. 12–13 alcohol abuse. clinician matrix. origins of the matrix in. 34–36. community for. 54. 88. 86. 88. 160. viii aversive control: addiction treatment and. 159 ACT Gone Wild. moving away as. appetitive control and. 27. 100– 102. human. 85. working with. 30–31. 105. 21–22. 82–83. 94–96. matrix for working with. groups used for. 241–243. functional analytic psychotherapy and. 160–161. 158. 89. 1–2. matrix model and. iGro measurement system for. See also substance abuse aikido. 103–104. 80–91. 149. chronic pain and. UK context for. 87–89. 159 avoidance cycle. recognition of. hexaflex diagram used in. chronic pain. 84–85. 47–48 Association for Contextual Behavioral Science (ACBS). See also committed action adaptation. 78 addiction treatment: activities for. 85–86. substance abuse and. 22–23. 28–29. client matrix. 221. motivations behind. 86. 245 addiction: definition of. 90. stress management using. 88. aversive control and. 77–78. 90–91. 88–89. 171–173 appetitive control: addiction treatment and. 152–155 away moves. 85–86. viii actions: linked to values. diversified locations for. 91. See substance abuse Altenloh. stages and barriers in. 81. 58–61. 137. . 129–145. 195. discrimination repertoire evaluation. 193–194. Mary Alyce. 54. 103–104 Chronic Pain Acceptance Questionnaire (CPAQ). 198–201 Cereal Box metaphor. 131–138. Marie-France. 43–44 Burkhart. clinician challenges with. 71–72. away moves. 185–186. client matrix for. example of using the matrix for. 198. terminating therapy for. 200–201. clinician matrix for working with. unwanted mental experiencing and. 211 committed action. 68. decisions. 225 body-mind conflict. ACT assessment of. 100–101. 134–137. 72. values related to. 10. therapist behaviors in. left side conceptualization. 124 body scan exercise. . 104–105. 95–96 clinically relevant behaviors (CRBs). 188–189. examples of matrix dancing with. creative hopelessness and. 136 blueberry bush story. See organizational settings C cartoon character voice. right side conceptualization. choices vs. 106. 129–131 chronic pain. matrix for working with. 158 collaboration. 104–105 choices vs. 191–193. 102–103. 138–142. 213 biomythologies. 210. 184 Bull’s-Eye Worksheet. 125 Bolduc. 109–110. See also toward moves B basic assumptions. 202. 196–197. 131–138. 100–102. tracking progress based on. 57. 132 clinicians. willingness and. 165–166. 182–183. self-as-context and. Andrew. 187–202. significant history recorded for. 199–200. 186. acceptance and. 105. treatment guidance 258 based on. alternative to linear. strengths and potential difficulties. 99–100. 136 Chessboard metaphor. 184–185. relevant contextual factors in. See therapists cognitive distancing. human mind and. 95. 73–74 challenging patients. 181–204. 190. 93–106. 51 case conceptualization. decisions and. 147 business settings. 183–184. 202–203. 100–101 chronic and severe symptoms. worksheet for. discriminating from toward moves. 197–198. overview of behaviors indicating. 132–133. 133–134. 94–96. noticing toward moves in. eating-disordered clients and. values identification and. 195–196. shared by therapists. 103–104. client strengths explored in. 16–17 Bezila. toward moves. 60–61 clinician matrix. 130–131 chemical imbalances. 96–106. 142–144. Passengers on the Bus metaphor for. values considered in.The ACT Matrix 133–134. quantifying matrix processes. workshop trainer. 231–232. explanation of RFT and. hooks based on. 236–237. 134–135 cooperation.Index cultivation of. 66–67. 66–67. 111–112. experiential noticing. 158 compulsions. 26–27. 46–47 drug abuse. noticing. 25. 124–126. 83 decisions vs. matrix process and. 123–124. cultivating. 47 distress-producing behaviors. 238. language and. home practice in. thoughts related to. 9. setting up. workability assessment and. 240 exercises: body scan. 252. identifying unwanted. See substance abuse dysfunctional behaviors. 50. 231. experiential learning for. 41. getting hooked by. noticing workable/unworkable behaviors in. 49–50 evolution: Darwin’s theory of. hexaflex processes and. 208–220. 48 Curtin. 244–245 couples work. 100–101 defusion. 236 decentralized groups. 73–75. 126–127. 123–124. 158 deictic framing. 35. 231 D Darwin. 28–34. 173–175 diagnostic away moves. 81 differences. Charles. traditional learning in. matrix for working with. 244–245 comprehensive distancing. 124–126. 131 DOTS approach. 169–171 conflict: body-mind. 113–123. choices. mental experiences in. Aisling. 127. 34 demographic details. 74. 13. 124. moving toward flexibility using. 123–124 educational settings: matrix use in. values clarification for. 133 dialectical behavior therapy (DBT). 130–131 E eating-disordered clients. 237 contextual behavioral science. hooks experienced by. 20–22. sorting related to. case example of working with. the matrix used with. 180 creative hopelessness: chronic pain and. 35. 58–59 derived relational responding: cued by the matrix. promoting involuntary. 32 despair. sensations of hunger in. 240–241 consequences. eatingdisordered clients and. 111–112. two-matrix perspective in. 126. 209 emotions: definition of. learning principles for training. 112–123. 46. language and. 109–128. 73–75. 50–51. committed actions engaged by. 18–19 distraction strategies. client stuck in. 139 depression. 11–12 discriminations. 46. 74. therapeutic relationship with. watching reactions to. 23–27. inner vs. hooks and moments of. 125. perspective taking in. 259 . 73. 109–110. 242. 99–100. combining values in. 125. 159 communities. 75. 121–122. 46. exercise used for. 8–9. 34–36 home practice. 61. A (Tsai. 127. 247–248. 54 H Hambright. 43. 33. 243 G generalization. mental. 49. 20–22. Russ. 156–158. unhooking from. Jerold. derived relational responding and. 13. 124–126 hypercontrol. 242 heritability. trauma memories as. 46. 18–19. exercise on noticing. See also metaphors. 57 “Happy Birthday” tune. 247–249. 158. 88 . 211. format and guidelines for. 250. 18–19 explicit sorting. school setting for. and Kanter). 111–112. 26–27. in-the-moment functional analysis. 211. 75. 67–68 frames of opposition. emotions as. 11. 24. 58–61. 60–61. 157. 125. 36–37 in vivo exposure. 51 harm reduction. 103. 46 Hayes. 60 Get Out of Your Mind and Into Your Life (Hayes). five-senses vs. valued action and. 231. 82–83. 126. 149 Individualized Generic Recovery Outcomes (iGro). 211–212. 42–43 Flexi and Spiky characters. 2. 237 hexaflex diagram. See functional analytic psychotherapy five-senses experiencing. noticing. functions of. 81–82 groups: addiction treatment in. Ostrom’s principles for. 54–55. Kohlenberg. 66–67 hooks: chronic pain and. 82–83. 246. educational settings and. 36–37 exposure therapy. worksheets experience: content vs. 11. 52. 101–102 Hook metaphor. 88 implicit sorting. psychological flexibility in. viii. 29 functional analytic psychotherapy (FAP): FAP rap given in. couples work and. defusion exercise for. 13. Matrix Mindfulness. Steve. eating-disordered clients and. secondary school students and. 66–67. 242 the grid. 73. 245–246. 8–9. 86 Harris. 82–83.The ACT Matrix 140. 208. training leaders of. the matrix and. noticing hooks in. 217. 128 I iGro system. 235–237. matrix work in. 240–241 human mind. 81. 231 human conflict. 102–103 hunger. 60–61. 121–122. 62–63. 62 functional contextualism. 148–149 F FAP. 16–17. 157–158. 90 260 Guide to Functional Analytic Psychotherapy. integrating with ACT. 173–175 loops around the matrix. spotting outside of sessions. 7–14. 100 Marasco. 46–47 “just noticing” exercises. social function of. 41–48. 30–31. 212 the matrix. origins and development of. right side work using. quantifying quadrants in. evolution of. 169–180. 178–180 intrapersonal processes. 209 left side work. 10 interpersonal processes: couples work and. 62. relationship-centered clinical practice and. 198–201 Matrix Mindfulness Exercise. two-matrix perspective in. 73–75. 95. natural process of. 33 mechanistic view. 140 Kabat-Zinn. addiction treatment using. importance of. 80–91. relational frame theory of. 251–252. mental experience and. risk viewed through. left side work using. psychological flexibility warm-up. matrix spotting in. 243–244. 208–220. 52–53. 26. 186. case examples of using. chronic and severe symptoms and. 190. 236 medical model. hexaflex diagram and. PTSD and. 59 involuntary derivations. 13–14. 126–127. clinician. Lynda. 181–204. 237–241. explanation of processes in. self-disclosing to clients. modeling intrapersonal and. 148–149. 12. educational use of. 33. 64–65. 61–71. 240. inner vs. derived relational responding cued by. private psychiatric practice and. 163–180. 112–123. 129. group work based on. 28–30 loneliness and despair. functional analytic psychotherapy and. 34–36. introducing to the general public. 60–61. 111–112. business use of. inflexibility of. 221–234. 8. 147–162. 137 261 . chronic pain and. 52–54. 131–138. 136–137. 124–126. 239. 16. 54–55. 240–241. evolution and. 32 IJK Join the DOTS approach. 96–106. two discriminations and. 243. summary points about using. 68. Jon. integrating ACT with. organizational use of. 188 L language: double-edged sword of. how it works. mental experience vs. relational frame theory and. 239–240. 138–144. case conceptualization based on. 196– 197. 72. 247–249 M Man in the Hole metaphor. three senses of self and. 59. 184–185. 73. human conflict and. 48–52. 247. traps based on. eating-disordered clients and.. 221–234. 28–34. 28–30. 247–249. 18 Matrix Case Conceptualization Worksheet. 72. 158–161. 124–126. 109–110. 72. home practice related to. 49 me noticing. 68. 58–59. 130 medication. 68. 210 learning: experiential.Index inner experience: explanation of. unwanted. 1–2. 113–123. 252. sorting stories into. 43. 106. 95. 42–43. 103–104 Passengers on the Bus metaphor. 147. 18–19. experiential training of. 96–106. 44. 43 persistent behaviors. 235. 232–233. 252 P pain: ACT assessment of.. 46–47. 66–67. See also thoughts metaphors: Cereal Box. 45–46. 66–67. 68. Hook. 102–103. 71 pervasive behaviors. 95. Kevin. 237. 212 Path Up the Mountain metaphor. Man in the Hole. See also exercises mind. case examples of matrix work in. self-as-context and. 130 personal away moves. matrix for working with. Path Up the Mountain. human. 104–105. 73–74. illustration of. 1. 7. 160 . presentmoment awareness as. 235. Passengers on the Bus. 100– 102.The ACT Matrix memories. 143–144. hooks. 211. 32–34. 134 perspective taking: couple communication and. unwanted. 24 opting out. 32–34. 15. matrix for working with. 159–160. creative hopelessness and. 17. noticed by therapists. 249. 18–19 Polk. See also PTSD mental experiences: clinician matrix and. 160. 236. 141. vii–viii. 104–105. 212. 211. 9. 245 Ostrom’s eight core principles. 132–133. 94–96. Passengers on the Bus metaphor. 82. inner experiences vs. 231 Newtonian physics.. 157–158. 103–104. 252. 13. 43. Values as a Cube. Chessboard. 47 organizational settings: ACT for managing stress in. 102. Elinor. strategies used to avoid. 221. cultivating. trauma: hooks related to. 222–227 Ostrom. 223–229. shifting to. terminating therapy with. acceptance and. 124– 126. 130 pliance. 11–12. 105. 95. 156–158. 49–50. getting hooked by. 8–9. 251 post-traumatic stress disorder. 140 multiple exemplar training. 21. benefits of 262 using the matrix in. 104. 81. 208. 26 point of view. 105. overview of. working on. human mind and. embracing. 57. 132–133. 239 noticing: differences. five-senses experiences vs. 26. 26–27. working with teams in. 100. See PTSD present-moment awareness. 27. 188. 99–100. willingness and. 245–246. practice of. 25 N nerves. values emphasis and. values identification and. 160 O observer perspective: self-as-context and. self-as-context and. 250. 97–98. 105. See also chronic pain pain matrix. 96–106. 74. 102–103 mindfulness: chronic pain and. Surfing. group behavior and. avoidance cycle in. 20. 30–31 risk. 148. 165–169. 134–135 prolonged exposure (PE) therapy. toward-away discrimination in. 98–105. 212. long-term change and. 85–86 relational frame theory (RFT). sorting process for. 129 PUSH community. 57. sufferingvalues connection in. special clinical skills in. 252. introducing the matrix in. 178–180. 21. 149. school setting and. 136–137 Rodriguez. basic assumptions of.Index private psychiatric practice. Emily. 247–248. 169–180. Rob. prolonged exposure therapy for. 7–14. Florian. 209 science. explanation of matrix processes for. 247 Psychological Inflexibility in Pain Scale (PIPS). warm-up for. the matrix used in. making space for. 156–158. 18–19. 167–168. in vivo exposure used for. viii root metaphors. 168. 131. 166–167 professional self. See relational frame theory right side work. 34–36. 15. 164–165. 150–152. two-matrix perspective used in. 147–148. 238. though the lens of the matrix. 243. self-as-context and. hexaflex diagram and. 218 psychological flexibility: ACT and. 156 purposeful living. noticing hooks for. 237–241. derived relational responding in. 16–17 self. 89 Q quantifying matrix processes. 96 PTSD. 163–180. 52–54. reinforcing toward moves in. stretching toward. 181. 207–220. 109 Schoendorff. 148–149 Prompted Bull’s-Eye Matrix Worksheet. 168–169 RFT. 251 school settings: matrix use in. 241. 211. 161–162. three senses of. 213. Benjamin. making space for resistance in. traditional learning in. 71–73 resistance: behaviors indicative of. presenting the matrix for. 148–149. 43. 152–155. noticing hooks related to. 73–75. 32–33 263 . 167. examples of matrix use in. experience of trauma and. 147–162. matrix for increasing. See also language relational framing. pain matrix and. dealing with. stuckness of clients in. 246. 23. modeling as ACT trainer. 168–169. point of view and. 61–71. 208–220. 10. 28 relationship-centered clinical practice: couples work in. 158–161. 150. 45–46 prosocial behaviors. 28. 140 Purssey. validating client suffering in. 196–197 R relapse patterns. 17 S Saffer. 229–232. explanation of. 33. 106 therapeutic away moves. 161 self-compassion. teachers stuck in severe. 25–26. 133–134 therapeutic relationship. 33. 52 severe symptoms. organizational: case example of matrix work with. 72 self-harm. 25–26 suffering: connecting to values. 129 T teachers: matrix use by. 166–167 suicidality. 227–229 stretching exercises. 160–161. 188 symptoms: chronic and severe. 58–59 sorting: behavior by successive approximations. 64–65. 211 self-as-process. unworkable behaviors defined as. 32–34. 32. 104. groups for working with. 249–250 storytelling. 73–75 Sid and Fido story. 221. 62–63. 138–145. 198 60 Ways to Use the Matrix (Webster). 81. 24. 12. 102–103 significant history.The ACT Matrix self-as-content. 130 stuckness. 19–20. validating in clients. 25. 161–162 self-as-expert thinking. 10. 67–68 spoke diagram. 129–131. 211 self-as-context: chronic pain and. 12. experiential training of. 82–83. treating in the UK. 221 shared matrix work. 154–155. 208–220. See also addiction treatment successive approximations. 47. 29 Tenaglia. client. 239 social support. 207 terminating therapy. 33. overview of matrix use with. clinical relationship and in-the-moment.. 78–79. 83 Skinner. observer perspective trained by. 104. 199 stress: effectiveness of ACT for managing. stories into the matrix. psychological flexibility and. 33. 82. me noticing as. See chronic and severe symptoms Seys. stuck in severe stress. Phil. 65–66. Kirk. 167. 136–137 self-nurturing. 244–245 social language. B. See also educational settings teams. 104–105. 134–135 Serenity Prayer. 78. 109–110 . 160–161. 149 substance abuse: addiction and. Annick. explicit to implicit. 32. 80–91. F. 252. avoiding pain with. matrix model and. 223–227. 227–229. 222–223 temporal frames. 20 Strosahl. 50 self-disclosure. 136–137 Surfing metaphor. 24 small groups. 26. 156 Spiky and Flexi characters. 156 264 strengths. 47. 167–168 subjective units of distress scale (SUDS). 36–37. matrix diagram illustrating. modeling of psychological flexibility by. 45–46. 166–167 Valued Living Questionnaire (VLQ). 81. 133–134. 95 values. 10. 69–70.Index therapists: away moves of. 239. Mark. 64–65. 140. 236–237 verbal aikido. 132–133. thoughts distinguished from. 90. See also mental experiences topographic diagnosis. reinforcing in clients. 213 WILD acronym. 25. 110. 47. thinking distinguished from. 109–110. 49. mindfulness related to. 211 V validating suffering. multiple exemplar. clarifying in matrix work. 32–34. matrix for working with. 71–72. 10. emphasizing with clients. 134–137. perspective taking. self-disclosure by. 209 Vincent. 168. eating-disordered clients and. 132. See also PTSD tug-of-war example. 27. private practice of. conceptualization behaviors of. 100–102. 159. 163 W Webster. suffering connected to. 79 two-matrix perspective. 32–34 trauma: different responses to. 57. 77 White. 147–148. working on memories of. 87 willingness. 195. values identified by. clinician matrix and. 12–13 verbal learning. 135 toward moves. 165–166. 33. 43–44. 200–201 training: addiction treatment. 230–231. clinician matrix. watching reactions to. mental experiences. 22–23. unwanted mental experiencing by. 15. identifying unwanted. personal cultivation of. 139–140. personal matrix for. chronic pain and identifying. 139. emotions related to. 45. 2. 178–180 U unhooking: defusion skills for. 124 12-step programs. 132 thinking: Newtonian perspective on. shared by therapists. self-as-context. 231. 131–138. 141. 229–232. 9. client matrix. addiction treatment based on. Dawn. 123–124. toward moves for. 72. 230–231. 105. See also hooks unwanted experiences: inner experiences. 93 variability. Amanda Adcock. Jean-Michel. clients not caring about. 167 Values as a Cube metaphor. 47 thoughts: definition of. 243. discriminating from away moves. 45–46. 185–186. 103–104 265 . 132–133. actions linked to. noticing in away moves. 72. 163–180. 159–160. 242. See also away moves tracking client progress. 150. perspective taking as. 137. 44 Vander Lugt. 30–31. 142. Bull’s-Eye Worksheet. 100–102. 134–137. 43–44. benefits of using the matrix in. Matrix Case Conceptualization Worksheet. Prompted Bull’s-Eye Matrix Worksheet. assessing. 43 XYZ “Yes. working with teams in. 222–227 worksheets: Bull’s-Eye Worksheet. 225 workability.. 232–233. 252. 45–46 WTF (“what’s the function”) acronym. 47–48 workplace: ACT for managing stress in. 186. ix. 190.The ACT Matrix Wilson. 221. case examples of matrix work in. 198–201. 12–13 Uploaded by [StormRG] 266 . and?” inquiry. 223–229. 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