Acceptance-based behavioural therapy

1. Introduction

Version followed: Roemer & Orsillo's individual ABBT for generalized anxiety disorder (GAD) as delivered in the 16-session randomised trial protocol (Hayes-Skelton, Roemer & Orsillo, 2013), organised by the chapter structure of their 2020 clinician text Acceptance-Based Behavioral Therapy: Treating Anxiety and Related Challenges (Guilford). The free trial manual listed by NREPP, the 2009 book (Mindfulness- and Acceptance-Based Behavioral Therapies in Practice) and the client book The Mindful Way Through Anxiety (Orsillo & Roemer, 2011) are not drawn on here; detail that depends on them is marked [uncertain].

Acceptance-based behavioural therapy (ABBT) is an individual outpatient cognitive-behavioural therapy that adds acceptance, mindfulness and values-based practice to traditional behavioural methods. It was developed for GAD and is now presented by its authors as a flexible framework for anxiety and co-occurring problems rather than a fixed protocol. [source: NREPP profile; Guilford 2020 product and contents pages]

Core idea of change: GAD is maintained by a restricted, self-critical, reactive and fused relationship with one's own thoughts, feelings, memories and sensations. This leads to rigid, habitual efforts to avoid or control those experiences (experiential avoidance, of which worry is one form) and to behavioural restriction, meaning people stop doing what matters to them. Change comes from three linked shifts:

a curious, compassionate, decentred stance towards internal experience (mindfulness);
willingness to have those experiences without trying to get rid of them (acceptance);
more engagement in valued activity, chosen on the basis of values rather than anxiety avoidance.

The goal is explicitly not anxiety reduction or changing the content of thoughts. [source: NREPP profile; Hayes-Skelton et al. 2013; DOAJ abstract of an Iranian ABBT trial; CounsellingResource review of Roemer & Orsillo 2009]

2. Framework

Format (trial version). 16 individual sessions over about 18 weeks. Sessions 1 to 4 last 90 minutes and are weekly. Later sessions last 60 minutes and are weekly, then taper to every two weeks across sessions 14 to 16. NREPP describes this as 14 weekly plus 2 biweekly sessions. Adaptations exist: a 12-session version of about 90 minutes per session (Iranian trial, used with developer permission), a group format, a Spanish manual and a Puerto Rican cultural adaptation. [source: Hayes-Skelton et al. 2013; NREPP; IRCT protocol] The 2020 book does not prescribe a session count on its contents page; its Appendix C gives a model for spreading topics, exercises and forms across sessions [uncertain: appendix].

Pre-treatment meeting(s) and case formulation (before session 1). Goals:

understand the client's own view of their worry;
assess contextual stressors such as financial, housing or family crises;
briefly explore cultural identity;
review past medication and therapy;
address practical obstacles to attending;
build hope.

In the 2020 book, assessment feeds an individualised case formulation built around the ABBT model, and this formulation is shared with the client together with a treatment plan before skills work begins (Part I, ch. 2–3). [source: Hayes-Skelton et al. 2013; Guilford contents]

Phase 1: cultivating acceptance-based skills and clarifying values. This phase runs roughly sessions 1 to 7 (Hayes-Skelton et al. 2013) or 1 to 8 (NREPP) [uncertain: the boundary differs by source]. Goals:

teach the acceptance-based model of anxiety: what anxiety and emotions are for, how emotions become intensified or "muddy", and the costs of trying to control or avoid internal experiences;
build mindfulness through a graded series of formal and informal practices;
cultivate an accepting, willing, decentred and self-compassionate stance;
clarify values through written exercises in three domains (relationships; work, school or household; self-care and community engagement);
move towards early commitments to mindful action in those domains.

[source: Hayes-Skelton et al. 2013; NREPP; Guilford contents Part II]

Phase 2: promoting mindful, valued action. This phase runs roughly sessions 8 or 9 to 16. Goals:

each week, the client chooses and carries out valued actions while applying mindfulness and acceptance skills to the discomfort that arises;
the client learns to notice obstacles to valued action;
when the client slips back into control or avoidance, therapist and client return to the Phase 1 concepts;
the therapist addresses contextual inequities and external barriers to valued action (2020 book, ch. 10).

[source: Hayes-Skelton et al. 2013; NREPP; Guilford contents Part III]

Ending (sessions 14–16, tapered). Goals:

review the changes the client has made;
identify which strategies helped most;
plan how to keep up gains after treatment (relapse prevention);
evaluate progress.

[source: Hayes-Skelton et al. 2013; NREPP; Guilford contents ch. 11]

Every-session structure.

Open with a mindfulness practice.
Review between-session practice and monitoring, including activity in valued directions.
Cover the session-specific content.
Agree new between-session practice.

In the 2020 book, all three ABBT goals are woven into every session (ch. 9): the formulation and model, acceptance and values skills, and mindful valued action. [source: Hayes-Skelton et al. 2013; NREPP; Guilford contents]

Criteria for moving on. The sources describe the phase shift by session number, not by explicit mastery criteria [uncertain]. Practical markers [synthesis]:

Move into Phase 2 once the client can describe the model in their own words, can name at least some "clear" emotions beneath "muddy" ones, practises mindfulness between sessions at least some days, and has written about values in all three domains.
Begin tapering once the client is reliably choosing and carrying out valued actions with anxiety present, and can catch and respond to their own slips into avoidance.

The sources describe skills building gradually; a model-process thesis on the trial data found that mindfulness, acceptance and valued action each rose steadily across the 16 sessions. [source: Marando-Blanck 2020 thesis abstract]

3. Guiding principles

[source for principles 1–9: NREPP; Hayes-Skelton et al. 2013 (including its adherence checklist); Guilford contents; CounsellingResource review. One-line practical meanings are [synthesis] unless cited.]

The problem is the relationship with internal experience, not the experience itself. Target fusion, self-criticism and avoidance, not the presence of worry or anxiety.
The goal is valued living, not anxiety reduction. Never frame success as feeling less anxious. The trial adherence checklist prohibited framing the goal as anxiety reduction.
Do not try to change the content of thoughts. The trial adherence checklist prohibited stressing the importance of changing cognitions. Help the client observe thoughts as thoughts, without disputing them.
Willingness and acceptance are alternatives to control. When a client tries to make anxiety go away, explore what that costs them and offer willingness instead.
Mindfulness is curious, compassionate, non-judging, present-moment awareness. Practise it every session and between sessions, starting with simple practices and moving towards difficult material. The CounsellingResource review notes the book defines mindfulness via Kabat-Zinn.
Relaxation and mindfulness practices must not become control strategies. Using relaxation to control anxiety was a forbidden strategy in the trial. Listen for "I did the breathing to get rid of it" and reframe gently.
Values are present-centred directions, not goals to achieve. The 2009 book calls values present-centred, prompting ongoing engagement (p. 143, as quoted by CounsellingResource). Ask what matters in how the client lives this week, not what they want to have achieved.
The therapeutic relationship is both the context for change and a mechanism of change (2020 book, ch. 4). Model acceptance, validation and compassion towards the client's experience in the room. Empathic validation is a named component of the trial protocol.
Individualise through the case formulation. The authors call ABBT a flexible framework. Pick examples, exercises and values domains that fit this client's formulation and cultural context.
Take context seriously. Some barriers to valued action are external: inequity, discrimination, poverty, caregiving load (2020 book, ch. 10). Validate these as real rather than treating them as avoidance, and problem-solve within them. [source: Guilford contents; Hayes-Skelton et al. 2013 pre-session assessment]
Self-compassion is cultivated directly (2020 book, ch. 7). Respond to self-criticism with mindful awareness and kindness, not argument.
Learning is experiential. Prefer an in-session demonstration or practice followed by a debrief over a lecture. The trial protocol paired psychoeducation with experiential exercises. [source: Hayes-Skelton et al. 2013; IRCT protocol]
Collaboration and transparency. Share the formulation and treatment plan openly, and agree between-session work rather than imposing it. [source: Guilford contents ch. 3]

4. Intervention inventory

How to read this section. The inventory below lists every intervention named in the sources:

the trial description (Hayes-Skelton et al. 2013);
the NREPP materials list;
the 2020 book's chapter list and audio-track list;
the IRCT protocol summary.

None of these sources give step-by-step scripts. The steps and example wording are therefore my own operationalisation [synthesis], consistent with the stated aims of each component. Handouts and forms are described, not reproduced. The book contains 29 reproducible handouts and forms; individual titles were not visible except where named below [uncertain].

4.1 Pre-treatment assessment and contextual interview

Purpose / when: Before session 1. Gather the information needed for an ABBT case formulation and lay the groundwork for engagement. [source: Hayes-Skelton et al. 2013; Guilford contents ch. 2]
Steps:
1. Ask the client how they understand their worry: what they think causes it and what they have tried.
2. Map current contextual stressors, such as money, housing, family crises, discrimination and caregiving.
3. Briefly explore cultural identity and what it means for how the client views emotion, help-seeking and values.
4. Review past therapy and medication, and what was and was not helpful.
5. Identify practical obstacles to attending and plan for them.
6. Gather model-relevant information [synthesis]: what internal experiences the client fights or avoids (worry content, bodily sensations, emotions, memories), how they respond (worry, reassurance-seeking, distraction, self-criticism, avoidance of situations), and which valued areas of life have narrowed.
7. End by conveying realistic hope.
Example language (illustrative): "Before we start, I'd like to understand worry the way you experience it, and what else is going on in your life that weighs on you."
Watch for: Stressors that are urgent and external (an eviction, for example), which need practical attention and are not avoidance. Also check for comorbid diagnoses, since trial outcomes also tracked comorbidity, and for anything requiring a risk assessment [synthesis]. Process measures are listed in Appendix A of the 2020 book. Specific instruments are [uncertain]; the trial thesis tracked mindfulness, acceptance and valued action weekly.

4.2 Sharing the case formulation and treatment plan

Purpose / when: End of assessment or session 1. Help the client see their own difficulties through the ABBT model and agree on the treatment plan. [source: Guilford contents ch. 3]
Steps [synthesis]:
1. Draw the model with the client's own examples. A trigger leads to internal experiences (thoughts, sensations, emotions). These are judged critically and fused with ("this is dangerous", "I can't stand this"). That leads to attempts to control or avoid them, including worry itself. Those attempts lead to narrowing of life and more distress.
2. Ask the client whether this fits, and revise it with them.
3. Name the three treatment goals: (a) change how they relate to internal experiences (more curious and compassionate, less fused); (b) reduce experiential avoidance and build willingness; (c) increase mindful action in the areas of life that matter.
4. Explain the format: session length and number, between-session practice, the two phases, and tapering at the end.
5. Be explicit that the aim is not to eliminate anxiety.
Example language (illustrative): "It looks like a lot of your energy goes into trying not to feel anxious. And the more you fight it, the more space it takes up, while things you care about get pushed aside. What we'll work on is changing that relationship, not getting rid of anxiety itself."
Watch for: Disappointment that anxiety will not be "removed". Validate this, and link it to the client's own experience that control attempts have not worked. Watch for agreement that is only intellectual; experiential work in later sessions deepens it.

4.3 Therapeutic relationship and empathic validation

Purpose / when: Throughout. In ABBT the relationship is both the context for change and a mechanism of change. Empathic validation is a named protocol component. [source: Guilford contents ch. 4; Hayes-Skelton et al. 2013]
Steps [synthesis]:
1. Reflect the client's emotional experience accurately and treat it as understandable given their history and context.
2. Model the stance being taught by noticing your own reactions in session (impatience, urge to fix, anxiety) and responding with curiosity rather than control.
3. Validate the function of worry (it is an attempt to protect or prepare) while exploring its costs.
4. Bring compassion to the client's self-criticism about their "failures" at practice.
5. Notice in-session avoidance (changing the topic, intellectualising) and name it gently and collaboratively.
Example language (illustrative): "Of course you'd want this feeling gone — it's genuinely painful. I notice that I want to help you get rid of it too. Maybe we can both just stay with it for a moment."
Watch for: Validation sliding into reassurance, which acts as a control strategy. Watch for therapist fusion with the client's urgency.

4.4 Psychoeducation: the acceptance-based model of anxiety and worry

Purpose / when: Phase 1, starting in session 1. Give the client a shared framework. Topics: the nature of worry and anxiety, and how attempts to control or avoid internal experience maintain distress. [source: NREPP; Hayes-Skelton et al. 2013; IRCT protocol]
Steps [synthesis]:
1. Explain that anxiety is a future-oriented response that prepares us for threat, and that it is normal and functional.
2. Describe worry as mostly verbal, "what if" thinking that can briefly feel like problem-solving or protection, yet keeps attention in the future and away from the present.
3. Link this to the client's monitoring data.
4. Give a written handout to take home. The authors use handouts; their wording was not seen.
Example language (illustrative): "Worry often feels like it's keeping you safe or prepared. Let's look at what it actually does for you, and what it costs."
Watch for: Clients hearing "worry is bad, stop worrying". This is another control goal. Correct it: the aim is to notice worry and choose a response.

4.5 Psychoeducation: the function of emotions, and "clear" versus "muddy" emotions

Purpose / when: Phase 1. Help clients see emotions as informative and functional, and understand how emotions become intensified or "muddy". The 2009 book includes a handout on the function of emotions. [source: Hayes-Skelton et al. 2013; CounsellingResource]
Steps:
1. Explain that emotions carry information and prepare action. For example, sadness signals loss, fear signals threat, and anger signals a blocked goal or an injustice [synthesis].
2. Introduce the distinction. "Clear" emotions are direct responses to the present situation. "Muddy" emotions are intensified, confusing or prolonged. In the ABBT literature, factors that muddy emotions include, as I understand them, lack of self-care (fatigue, hunger), reactions carried over from the past or worries about the future, and reacting to the emotion with judgement or struggle. [uncertain: the trial paper names "muddy" emotions; the list of contributing factors is from secondary memory of the Roemer & Orsillo materials]
3. Use a recent episode from monitoring. Ask: what was the clear response to what happened? What made it muddier?
4. Assign monitoring of emotions, noting clear and muddy aspects.
Example language (illustrative): "Underneath the panic about the meeting, was there something more direct — maybe disappointment about how it went last time? The panic might be the muddy layer, with the disappointment as the clear signal."
Watch for: The client using "clear" to mean "acceptable" and "muddy" to mean "wrong". Both are understandable; the distinction only helps the client respond more skilfully. Signs it is working: the client names emotions more precisely, and notices fatigue or past-or-future fusion as amplifiers.

4.6 Psychoeducation and experiential exercises on the costs of control and avoidance

Purpose / when: Phase 1. Help the client discover, through direct experience, that trying to suppress or control internal experiences often backfires. Then introduce willingness as an alternative. [source: Hayes-Skelton et al. 2013 ("psychoeducation and experiential exercises promoting acceptance"); IRCT protocol ("experiential demonstrations"); NREPP]
Steps [synthesis]:
1. Review the client's own control strategies from monitoring: worry, distraction, reassurance, avoidance, checking, self-talk.
2. For each strategy, ask: what does it do in the short term, and in the long term? What does it cost in time, relationships and vitality?
3. Run a brief experiential demonstration. A thought-suppression exercise is a widely used option: ask the client to try not to think of a specific neutral image for a minute, notice what happens, then debrief. [uncertain: the specific demonstrations ABBT uses are not specified; this is a standard acceptance-based demonstration, not confirmed as part of the ABBT manual]
4. Contrast the rules for the outside world ("if you don't like it, change it") with how internal experiences work ("the more you try not to have it, the more you have it").
5. Introduce willingness: choosing to allow experiences to be present while still acting.
Example language (illustrative): "In the outside world, effort usually pays off. Inside, it often works the other way — the harder you push a feeling away, the more it pushes back. What would it be like to let it stay while you do what matters?"
Watch for: Clients who agree but quietly redefine acceptance as a cleverer way to get rid of anxiety ("if I accept it, it'll go away"). Name this gently as the control agenda returning. Signs it is working: the client spontaneously labels their own control attempts and their costs.

4.7 Self-monitoring

Purpose / when: Begins in session 1 and continues throughout. Builds awareness (an early form of mindfulness), generates material for sessions and tracks change. Program materials include "Treatment Monitoring Forms"; the 2009 book includes an anxiety-awareness monitoring sheet. [source: Hayes-Skelton et al. 2013; NREPP; CounsellingResource]
Steps [synthesis]:
1. Start simply. Each day, the client notes when they noticed anxiety or worry, the situation, and what they did.
2. Over the following weeks, add columns as new concepts are taught:
  - emotions present (clear or muddy);
  - responses (control or avoidance versus willingness);
  - formal and informal mindfulness practice completed;
  - and, in Phase 2, valued actions taken and obstacles noticed.
3. Review the form at the start of every session. Thank the client for any data, and look for patterns together.
Example language (illustrative): "This isn't about writing down every worry — it's about practising noticing. Even catching it once or twice a day is useful."
Watch for: Monitoring becoming another rumination ritual, or failure to complete it. Simplify the form and treat incompleteness as data (see section 5). [uncertain: the exact form columns and the order in which they are added were not verified]

4.8 Medication monitoring

Purpose / when: For clients on medication. Program materials include medication monitoring forms. [source: NREPP]
Steps [synthesis]: Record medication changes during treatment and coordinate with the prescriber. Note whether medication is being used as an avoidance strategy, for example as-needed use before valued activities. Explore this with curiosity; never advise changes yourself.
Watch for: Unreported changes that confound progress. Content of the official form not seen [uncertain].

4.9 Formal mindfulness practice: general method and sequencing

Purpose / when: Every session opens with a mindfulness exercise, and the client practises daily between sessions.
- The practices progress from basic skills, such as observing the breath while sitting, to applying mindfulness in hard contexts, such as observing painful thoughts and emotions during a conflict.
- Guided audio for the practices in 4.10–4.18 comes with the 2020 book.
- The trial's initial therapists and supervisors were trained in mindfulness therapies by Zindel Segal.
- [source: Hayes-Skelton et al. 2013; NREPP; Guilford contents (audio list)]
Steps for every practice [synthesis]:
1. Give a short rationale linked to the formulation.
2. Guide the practice, live or with audio. Practise it yourself as you guide.
3. Debrief with open questions: "What did you notice?" Then: "How did you respond to what you noticed?"
4. Validate all experiences, including boredom, wandering and distress, as material for noticing.
5. Draw out the link to worry and avoidance.
6. Agree a realistic home practice: which recording, how often, and when.
Example language (illustrative): "There's no right experience to have here. If your mind wanders a hundred times, that's a hundred chances to notice and come back."
Watch for: Practice used as relaxation or anxiety control. This was forbidden in the trial; reframe it as practice in noticing, not in calming. Watch also for perfectionism about practice. Signs it is working: the client reports catching worry earlier and describing experiences more neutrally.

The practices below are listed in the order of the 2020 book's audio tracks. That this is the treatment order is an assumption [uncertain]; the general progression is from simple to difficult. Some practices are adapted from other mindfulness traditions: the Mountain Meditation is associated with Kabat-Zinn, and Inviting a Difficulty In with MBCT. [uncertain: attribution from secondary knowledge]

4.10 Mindfulness of Breath (about 3 minutes)

Purpose / when: A first, simple anchor practice in early Phase 1. It is the basic example of sitting meditation in the trial description. [source: Guilford audio list; Hayes-Skelton et al. 2013]
Steps [synthesis]:
1. Sit upright and comfortable, with eyes closed or gaze lowered.
2. Bring attention to the sensations of breathing wherever they are most noticeable, without changing the breath.
3. When the mind wanders, briefly note where it went ("thinking", "worrying") and gently return to the breath.
4. Close by widening attention to the room.
Example language (illustrative): "Just let the breath breathe itself. You're only noticing."
Watch for: Controlled or deep breathing, which is a relaxation strategy. Clients with panic may find breath focus aversive; offer sounds as the anchor instead [synthesis].

4.11 Mindfulness of Sounds (about 5 minutes)

Purpose / when: Phase 1. Practises receiving experience as it comes and goes without grasping or pushing away. It is a less body-focused anchor. [source: Guilford audio list]
Steps [synthesis]:
1. Rest attention on sounds near and far as they arise and fade.
2. Notice the urge to label, judge or tell a story about a sound ("that's an annoying car"), and return to hearing the raw sound.
3. Debrief the parallel with thoughts, which also arise and pass.
Example language (illustrative): "Notice sounds arriving and leaving on their own — you don't have to go and get them or send them away."
Watch for: Irritation at intrusive sounds. This is useful material on judging and resisting.

4.12 Mindfulness of Physical Sensations (about 3 minutes)

Purpose / when: Phase 1. Build curious, non-judging awareness of bodily sensations, including those linked to anxiety. [source: Guilford audio list]
Steps [synthesis]:
1. Move attention through areas of the body.
2. Notice sensations such as pressure, temperature, tension and tingling, and describe them in plain words.
3. When a sensation is unpleasant, notice the reaction to it (tightening, judging) as separate from the sensation itself.
Example language (illustrative): "See if you can describe this tightness the way a curious scientist would — where it is, its edges, whether it changes."
Watch for: Hypervigilance or catastrophic reading of sensations. Keep the practice short and debrief carefully.

4.13 Mindfulness-based progressive muscle relaxation (PMR), with 16-, 7- and 4-muscle-group versions

Purpose / when: The 2020 book includes an instruction track on mindfulness-based PMR and three PMR tracks of decreasing length (16, 7 and 4 muscle groups). [source: Guilford audio list]
- In ABBT, PMR is framed as practice in noticing tension and release, and in early detection of bodily signs of anxiety. It is not framed as anxiety control: using relaxation as control was a forbidden strategy in the trial. [source: Hayes-Skelton et al. 2013]
- How and when PMR is placed within the course of ABBT is [uncertain].
Steps [synthesis]:
1. Explain that the aim is noticing.
2. Tense each muscle group briefly, attending closely to the sensations of tension.
3. Release, attending to the change.
4. Move to the next group.
5. Over weeks, reduce from 16 to 7 to 4 groups as awareness sharpens. (This step-down mirrors the track lengths.)
Example language (illustrative): "The point isn't to make yourself relaxed — it's to get really good at noticing what tension feels like, so you can catch it earlier."
Watch for: The client reporting PMR as "working" because it got rid of anxiety, then becoming distressed when it doesn't. Re-anchor on noticing. Use caution with injuries and pain conditions: adapt or skip groups [synthesis].

4.14 Mindfulness of Emotions (about 5 minutes), and of Emotions and Physical Sensations (about 6 minutes)

Purpose / when: Mid Phase 1, after the function-of-emotions psychoeducation. Practise noticing and naming emotions and where they are felt in the body, with willingness. [source: Guilford audio list]
Steps [synthesis]:
1. Settle with a brief breath anchor.
2. Invite awareness of any emotion present, and name it softly ("sadness is here").
3. Locate it in the body and notice the sensations.
4. Notice reactions to the emotion (judgement, urge to fix), and make room for the emotion as it is.
5. Return to the breath to close.
Example language (illustrative): "See whether you can let this feeling be here, just for now, as a visitor you're curious about."
Watch for: Alexithymia ("I don't feel anything"). Start with body sensations. If distress escalates, widen attention to the breath and the room [synthesis].

4.15 Mindfulness of Clouds and Sky (about 7 minutes)

Purpose / when: Phase 1. Builds decentring: thoughts and feelings are seen as passing events, like clouds, against a stable background of awareness, like the sky. [source: Guilford audio list; decentring aim from Hayes-Skelton et al. 2013]
Steps [synthesis]:
1. Invite the image of sky and moving clouds.
2. As each thought or feeling arises, picture it as a cloud that appears, drifts and changes.
3. Notice when you are "in" the cloud (caught up in a worry), and step back to watching.
Example language (illustrative): "Notice that you can watch the worry-cloud go by, rather than being inside it."
Watch for: Using imagery to push thoughts away ("I sent it off"). The task is to watch, not to dispatch.

4.16 Mountain Meditation (about 8 minutes)

Purpose / when: Phase 1 into Phase 2. Uses the image of a mountain that stays grounded through changing weather and seasons, to cultivate stability while experiences change. [source: Guilford audio list; content inferred from the title, uncertain]
Steps [synthesis]:
1. Sit in a stable posture.
2. Picture a mountain, then imagine embodying it.
3. Let weather (storms, sun, snow) represent changing thoughts and emotions passing over a steady base.
Example language (illustrative): "Let the weather be whatever it is today. The mountain doesn't need it to change."
Watch for: Clients for whom imagery is hard. Offer a body-based anchor instead.

4.17 Inviting a Difficulty In and Working It through the Body (about 6 minutes)

Purpose / when: Later Phase 1 and Phase 2. A deliberate, willing approach to a difficult thought or situation while staying with its bodily expression. This applies acceptance to hard material, matching the trial's progression towards observing painful experiences. [source: Guilford audio list; Hayes-Skelton et al. 2013]
Steps [synthesis]:
1. Settle with the breath.
2. Bring to mind a moderate, current difficulty. Do not start with the worst one.
3. Notice where it shows up in the body.
4. Bring gentle, open attention to those sensations, perhaps breathing with them, and saying inwardly that it is all right to feel this.
5. When ready, return to the breath and the room.
Example language (illustrative): "Choose something that's a 4 or 5 out of 10 — not the hardest thing. We're practising, not testing."
Watch for: Overwhelm, or trauma memories surfacing. Get consent first, choose the material carefully, and offer an exit cue ("open your eyes and feel your feet whenever you need"). Do not use this practice for trauma processing [synthesis]. Signs it is working: the client can stay with discomfort longer and reports less struggle.

4.18 Self-compassion practices: "Your Personal Experience with Self-Compassion" (about 4 minutes) and "Mindful Observation of Self-Critical Thoughts" (about 4 minutes)

Purpose / when: Self-criticism is a core part of the ABBT model. The 2020 book (ch. 7) uses ABBT methods to cultivate self-compassion. [source: Guilford contents and audio list; NREPP model]
Steps [synthesis]:
1. Personal experience: Reflect on what self-compassion means for this client, and on times they have offered kindness to others or received it. Notice the reactions that arise (resistance, "I don't deserve it") with curiosity.
2. Self-critical thoughts: Invite the client to notice self-critical thoughts as they arise, label them ("a judging thought"), notice their tone and their effect in the body, and let them be present without arguing or agreeing.
3. In session, respond to the client's self-criticism with warmth, and ask how they would respond to a friend.
Example language (illustrative): "There's the critic again. Let's just notice it — what it's saying, and how it feels in your body — without having to obey it or argue it down."
Watch for: Fear of self-compassion ("I'll get lazy"). Explore this as a belief, and test it through experience. Signs it is working: the client catches self-criticism and responds more gently, including about missed practice.

4.19 Informal mindfulness and mindful engagement in daily activities

Purpose / when: From early Phase 1 onwards. Brings mindful awareness into ordinary activities, and later into valued activities, so that the client is present for what they do rather than worrying through it. [source: IRCT protocol ("formal and informal daily practice", "bringing mindful awareness to valued activities"); Hayes-Skelton et al. 2013]
Steps [synthesis]:
1. Choose a routine activity, such as washing dishes, walking or drinking tea.
2. Do it with full attention to the senses, noticing and returning when the mind wanders.
3. Gradually extend this to valued activities, such as playing with a child or a work task.
4. Record the practice on the monitoring form.
Example language (illustrative): "This week, when you're with your daughter at bedtime, see if you can notice when worry pulls you into tomorrow, and come back to her."
Watch for: The client doing mindful activities only on good days. Encourage practice on hard days too.

4.20 Decentred, willing stance: in-session coaching

Purpose / when: Throughout. The trial protocol teaches an "accepting, willing, and decentered stance" in which thoughts and feelings are seen as passing events, not facts or commands. [source: Hayes-Skelton et al. 2013]
Steps [synthesis]:
1. When the client states a worry as fact, reflect it back as an experience: "you're having the thought that...".
2. Invite them to notice the thought's pull and their urge to respond to it.
3. Ask whether a willing stance is possible right now, and what it would look like in action.
Example language (illustrative): "So the thought 'I'll be fired' showed up again. Can you notice it as a thought your mind is producing, and still choose what to do next?"
Watch for: The stance used to dismiss real problems. A thought can be noticed and still lead to sensible problem-solving when the problem is current and solvable.

4.21 Values writing assignments in three life domains

Purpose / when: Phase 1, between sessions, and revisited later. Clarify personal values in three areas: (1) relationships; (2) work, school or household management; (3) self-care and community engagement. This leads to commitments to mindful action in each area. Program materials include "Treatment Values Assignments". The 2020 book (ch. 8) covers articulating and clarifying values. [source: Hayes-Skelton et al. 2013; NREPP; Guilford contents]
Steps [synthesis, structure partly uncertain]:
1. Assign a private, uncensored writing exercise. The client writes for about 20 minutes on several days. The CounsellingResource review mentions stream-of-consciousness writing as homework in the 2009 book.
2. Exact prompts were not seen. In the ABBT materials, an early assignment is reported to focus on how anxiety and worry have affected each domain, and later ones on what the client values in each domain [uncertain: sequence not verified].
3. In session, read or summarise the writing together, highlighting emotions that came up and the themes of what matters.
4. Help the client put each value into words as a direction of living ("being an attentive, honest friend"), not as a goal.
Example language (illustrative): "Write about the kind of partner you want to be — not what you want to get from the relationship, but how you want to show up in it. No one else needs to read it."
Watch for:
- Values stated as "shoulds" or as other people's expectations. Ask: "If no one would ever know, would this still matter to you?"
- Writing that triggers strong emotion. Treat it as meaningful, and practise willingness with it.
- Signs it is working: the client can name specific, personal directions in each domain.

4.22 Distinguishing values from goals, and from anxiety-driven choices

Purpose / when: Phase 1 into Phase 2. Values are present-centred and support ongoing engagement, unlike goals, which are achieved and ended (2009 book, p. 143). The therapist helps the client choose actions on the basis of values rather than avoidance of anxiety. [source: CounsellingResource (quoting the 2009 book); NREPP; Hayes-Skelton et al. 2013]
Steps [synthesis]:
1. Take a decision the client faces and ask two questions: "Which choice would anxiety make?" and "Which choice moves you towards what you care about?"
2. Separate the value (the direction) from goals (milestones on the way) and from outcomes they cannot control, such as others' reactions.
3. Note that values can be acted on right now, even in small ways.
Example language (illustrative): "Getting the promotion is a goal. Doing work you're proud of is something you can live today, whether or not the promotion comes."
Watch for: Clients judging themselves for "failing" a value. Values are directions, not pass or fail tests.

4.23 Weekly mindful valued-action commitments

Purpose / when: Begins at the end of Phase 1 and is the core of Phase 2. Each week the client chooses specific valued actions and carries them out while practising mindfulness and acceptance towards the discomfort that arises. [source: NREPP; Hayes-Skelton et al. 2013]
Steps [synthesis]:
1. Pick one to three concrete, small actions linked to stated values. Spread them across domains over time.
2. Specify when, where and how.
3. Ahead of time, name the internal experiences likely to show up ("what if they think I'm stupid", a tight chest) and how the client will respond willingly (noticing, breathing with, labelling).
4. Record the outcome on monitoring forms, rating whether the action was done and how present the client was, not how anxious they felt.
5. Review next session: what happened, what got in the way, and what was learned.
Example language (illustrative): "What's one thing this week that would be a step towards being the friend you want to be — even if anxiety comes along for the ride?"
Watch for:
- Actions chosen to reduce anxiety, such as reassurance calls framed as "connection". Check what the action is for.
- Actions too large to succeed at.
- Success judged by feelings.
- Consent and safety for approach tasks [synthesis]: These actions often involve approaching feared situations, so get the client's explicit agreement and let them choose the pace. Never push for actions that are unsafe, such as contacting an abusive person. Screen first for panic, cardiac or other medical conditions where intense arousal is a concern.

4.24 Working with obstacles to valued action

Purpose / when: Phase 2. When the client falls back into control or avoidance, therapist and client revisit the Phase 1 concepts. [source: Hayes-Skelton et al. 2013; NREPP ("recognize obstacles")]
Steps [synthesis]:
1. Review a missed or abandoned action without judgement.
2. Identify the obstacle. Was it internal (fused thoughts, unwillingness, muddy emotion, self-criticism) or external (time, money, other people, structural barriers)?
3. Match the response to the obstacle:
  - internal obstacle: return to the relevant Phase 1 skill (mindfulness practice, the clear-versus-muddy distinction, willingness);
  - external obstacle: problem-solve, or adjust the action while keeping the value (see 4.25).
4. Recommit to a revised action.
Example language (illustrative): "Let's get curious about the moment you decided not to go. What showed up — thoughts, feelings, sensations?"
Watch for: Repeated "too busy" reasons, which may be avoidance or may be a real overload. Explore both possibilities.

4.25 Addressing contextual inequities and external barriers

Purpose / when: Whenever structural or external factors limit valued action: discrimination, poverty, unsafe environments, caregiving, immigration stressors. [source: Guilford contents ch. 10; Hayes-Skelton et al. 2013 (assessment of contextual stressors and cultural identity); NREPP (Puerto Rican cultural adaptation)]
Steps [synthesis]:
1. Validate the barrier as real and not just a thought.
2. Explore whether internalised messages (for example, internalised stigma) add to the distress.
3. Find ways to act on the value within the constraint, including collective or community action where that is a value.
4. Bring self-compassion to grief and anger about injustice.
5. Make referrals for practical needs.
Example language (illustrative): "This isn't something to just 'accept' — the barrier is real and unfair. Within it, what's one way you could still move towards what matters?"
Watch for: Misusing acceptance language in a way that invalidates oppression. Acceptance applies to internal experience, not to accepting injustice [synthesis].

4.26 Integrating the three ABBT goals in each session

Purpose / when: Mainly Phase 2. In the 2020 book (ch. 9), every session addresses (a) the formulation and model, (b) acceptance, mindfulness and values skills, and (c) mindful valued action. [source: Guilford contents; Hayes-Skelton et al. 2013; NREPP]
Steps [synthesis]:
1. Open with mindfulness practice, chosen for current needs.
2. Review monitoring and valued actions.
3. Link what happened to the model: what was avoided, and what was muddy.
4. Strengthen one skill.
5. Set the next valued actions and practices.
Watch for: Sessions drifting into general problem discussion or reassurance. Use the session structure to re-anchor.

4.27 Other named programme materials

The NREPP materials list includes a "Helpful Responses" worksheet with answers, mindfulness exercises, group adaptation materials and an adherence checklist and competence form. The trial checklist had 9 required strategies and 7 forbidden ones. [source: NREPP; Hayes-Skelton et al. 2013]
The content of the "Helpful Responses" worksheet was not seen. It may be a training exercise for therapists in choosing ABBT-consistent responses [uncertain]. Do not use this guide as a substitute for it.
Self-check from the adherence data (illustrative use) [synthesis]: After each session, ask yourself three questions. Did I frame the goal as reducing anxiety? Did I push the client to change their thoughts? Did I teach relaxation as a way to control anxiety? A "yes" to any of them means you drifted from the model.

4.28 Evaluating progress, relapse prevention and ending treatment

Purpose / when: Progress is evaluated throughout. In the trial, sessions 14 to 16 were spaced two weeks apart to support independence, and focused on reviewing change, identifying the most effective strategies and planning how to maintain gains. [source: Hayes-Skelton et al. 2013; NREPP; Guilford contents ch. 11]
Steps [synthesis]:
1. Review monitoring and measures from the start of therapy to now: worry, avoidance, practice, and valued actions across domains.
2. Have the client list the practices and concepts that helped most.
3. Predict future high-risk times, such as stress, illness or transitions, and the early signs of slipping back into control and avoidance (more worry, narrowing life, self-criticism).
4. Write a personal maintenance plan covering ongoing practice, valued actions in each domain, and what to do if old patterns return.
5. Frame lapses as expected and as chances to practise.
6. Discuss ending, including feelings about it, with willingness.
Example language (illustrative): "Anxiety will show up again — that's part of being human. What will tell you that you've started fighting it again, and what will you do then?"
Watch for: The client expecting to be "cured" of anxiety. Restate the ABBT aim. Fear about ending can be worked with as a final practice in acceptance.

4.29 Group and adapted delivery

Purpose / when: A group outpatient format exists, as do a 12-session version of about 90 minutes per session and cultural adaptations. [source: NREPP; IRCT protocol]
Steps [synthesis]: Keep the core components:
- psychoeducation with experiential demonstrations;
- monitoring;
- graded mindfulness practice;
- values writing;
- weekly valued actions.
When compressing to fewer sessions, combine psychoeducation topics but protect time for practice and valued-action review. The specific structure of the group manual was not seen [uncertain].

5. Handling problems

The sources say little about troubleshooting. What they do provide:

Revisit the Phase 1 concepts when the client falls back into control or avoidance.
Assess and address contextual stressors and external barriers.
Avoid the forbidden strategies: framing the goal as anxiety reduction, stressing cognitive change, and teaching relaxation as control.
The developer identified no adverse effects.

[source: Hayes-Skelton et al. 2013; Guilford contents ch. 10; NREPP] Everything else below is [synthesis] unless tagged otherwise.

Client keeps trying to use ABBT to get rid of anxiety (the control agenda returns). This is the most common ABBT-specific difficulty. [synthesis]

Do not argue. Ask about the client's experience: "When you practised to make the anxiety go, what happened?"
Name it kindly: "There's that old rule again: 'I have to feel calm first'."
Shift the measure of success to presence and valued action.
Check your own language for framing that implies anxiety reduction. [source for the prohibition: Hayes-Skelton et al. 2013]

Stuck: practice and monitoring are done, but life isn't changing. [synthesis]

Check that valued actions are actually being set and done each week, and that they are small and specific enough.
Look for subtle avoidance inside actions, such as attending an event while worrying throughout. Add informal mindfulness to the action itself.
Re-examine the values: are they the client's own?
Revisit external barriers (4.25).
If depression is prominent, start with very small, routine-based valued actions and add self-compassion work.

Non-adherence to mindfulness practice or monitoring. [synthesis]

Treat it as data, not defiance. Explore what got in the way: internal obstacles (it brought up feelings, "I did it wrong", boredom) or practical ones.
Shorten the practice. The 3- to 5-minute tracks exist.
Attach practice to an existing routine.
Practise more in session.
Simplify the monitoring form to one or two columns.
Use self-compassion with the client's self-criticism about missing practice.
Recheck the rationale: does the client see how practice links to what they care about?

Resistance to values work. Examples: "I don't know what I value", "it's pointless", tears. [synthesis]

Strong emotion during values writing often signals that something important has been lost through avoidance. Slow down and validate.
If the client is blank, use concrete prompts: moments they felt most alive, people they admire and why, what they would want said at a milestone birthday.
Accept tentative values: they can be revised.

Overwhelm during exercises, especially Inviting a Difficulty In or mindfulness of emotions. [synthesis]

Before you start: get informed consent, pick a moderate difficulty, explain the exit option, and keep exercises short at first.
If overwhelm happens:
1. Open the eyes.
2. Anchor attention to the feet on the floor, sounds in the room and the breath.
3. Name what is happening.
4. Debrief with validation.
Resume with less intense material later.
For trauma survivors, dissociation or flashbacks need trauma-informed adaptations: eyes open, shorter practices, external anchors. Consider whether trauma-focused treatment should come first or alongside.

Mindfulness increases anxiety at first. [synthesis]

Expect this, and say so in advance. Turning towards experience can make it feel more intense at first.
Offer anchors outside the body, such as sounds. For panic-prone clients, avoid breath focus at first.
Normalise this as part of learning to allow.

Ruptures ("You're telling me to just accept my problems"). [synthesis]

Own any misattunement.
Clarify that acceptance applies to internal experience and is paired with action, not resignation.
Validate any real external problem (4.25).
Repair openly and invite feedback. In ABBT the relationship is itself a mechanism of change. [source for relationship as mechanism: Guilford contents ch. 4]
Withdrawal ruptures, such as compliant but disengaged clients, call for gently naming the pattern and asking about the client's experience of therapy.

Reassurance-seeking from the therapist. [synthesis]

Notice the urge to reassure, in the client and in yourself.
Reflect the worry and the wish for certainty.
Invite willingness to stay with uncertainty, and link this to valued action.

Worry about therapy itself ("Am I doing this right?"). [synthesis]

Treat it as more material: "Can you notice the thought 'I'm doing it wrong' and keep going?"

Medication and other treatments. [synthesis]

Use medication monitoring (4.8).
Coordinate with prescribers.
Do not recommend changes.
Explore any as-needed use before valued activities with curiosity, not judgement.

Risk. [synthesis]

Screen for suicidal ideation and self-harm at intake and whenever depression worsens, using standard structured risk assessment.
Build a collaborative safety plan with crisis contacts and lethal-means counselling: safe storage, or removal by a trusted person.
Do not use acceptance framing for active risk. Acute risk takes priority over the ABBT session agenda.
ABBT was evaluated for outpatients with principal GAD. Acute risk, active psychosis, mania or severe substance dependence warrant other or additional care. [uncertain: trial exclusion criteria not verified]

Cultural fit. [synthesis]

Some clients may hear mindfulness as religious, or values work as individualistic.
Explore their meaning of the practices, offer secular framing, and include collective and family values.
A Puerto Rican cultural adaptation and a Spanish manual exist. [source: NREPP; Guilford contents ch. 10]

Training and fidelity gaps. Formal training is not required. Workshops and paid consultation are available, and NREPP reviewers noted limited fidelity and supervision guidance. [source: NREPP] [synthesis]: Self-rate a sample of your sessions against the required and forbidden strategies (4.27). Seek consultation if you have no mindfulness practice of your own; the trial therapists received mindfulness training.

Sources

Sources: