Numerous descriptions from the Case
Example of Yisel describes her as a stressed and anxious college student who is
suffering from demotivation and anxiety. Psychologists and therapists may
postulate that Yisel would have been diagnosed today with Generalized Anxiety
Disorder, Nightmare Disorder as well as Minor Depressive Disorder. However, it
seems like she still has a strong willpower and ability to continue her studies
despite the difficulties she’s currently faced with. Even though Yisel has come
to the counseling center seeking career counseling, I feel that she needs to ease
her stress and worries and learn effective time management skills before
focusing on issues related to career exploration. I decided that a third wave
approach of cognitive-behavioral therapy (CBT); mindfulness and acceptance-based
therapy would be helpful for Yisel, specifically integrating acceptance and
commitment therapy, or ACT using mindfulness, acceptance and values-based
behavior change strategies.

Yisel is currently struggling with
problems that many young adults go through. Primarily she is concerned about
the way her anxiety symptoms are affecting her academic performance and her
daily routine, especially her sleeping difficulties. Yisel is also feeling
extremely pressured because her parents have made immense sacrifices to enroll
her into university, which makes her feel remorseful and selfish. Her parents
immigrated to Minnesota from Mexico mainly for their children’s’ education and
future despite the language barriers and many documentation issues. Even though
she says her parents have never openly pressured her, she cannot help feeling overburdened
from her parents’ expectations of her becoming a doctor as well as her
financial assistance to help her younger brothers’ college tuition in the
future. Based on many of these expectations and pressures from external forces,
an ACT approach asserts that unwanted private events may form internally to
Yisel, such as distressing thoughts, feelings, and physiological events. She is
frequently having a difficult time completing school work due to procrastination
and lack of motivation. Rather than finishing work that needs to be accomplished,
it seems like she has been chronically avoiding difficult tasks and
deliberately looking for distractions by wasting her time online and with her
friends. For instance, the most common problems endorsed by individuals with
anxiety were procrastination, lower energy and productivity (Buckner, Heimberg,
Matthews & Silgado, 2012). Moreover, her sleep disturbances, predominantly
her nightmares that occur several times a week are related to the anxiety that
plagues her thoughts and worries, despite feeling tired.

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From an acceptance-based
perspective, Yisel’s problems are caused by excessive avoidant of experiences,
such as her procrastination and anxiety caused from consistent escaping from
reality. Moreover, it is reported that she is smoking marijuana daily in which
she does to help her feel more relaxed and forget about her emotional distress
and worries. According to Hayes et al. (1999) an ACT approach to these causes
is signified on the notion that Yisel’s anxiety disorders are characterized by
experiential and emotional avoidance (Hofmann, 2008). This can be defined as a
tendency to engage in destructive behaviors to alter the frequency, duration of
the problems, and the situations when such avoidance leads to problems in
functioning. (Hayes et al., 1999). It is likely that Yisel is using marijuana as
a means of coping with certain pressures from educational demands, family
relationships, and stress. The function of such experiential avoidance has
likely been controlling and minimizing the influence of aversive internal
experiences of Yisel. Furthermore, it is described that Yisel has been smoking
the illicit drug daily which may place her at risk for marijuana abuse and further
developing marijuana-related problems. Pope and Yurgelun-Todd (1996) argue that
heavy marijuana use is associated with residual neuropsychological effects even
after a day of abstinence from the drug. Despite that experiential avoidance
can produce immediate relief, these are short-term and negatively reinforce
such behavior. Through the course of these associations from the ACT approach, it
is evident that excessive avoidance of experiences becomes problematic as it
interferes with Yisel’s everyday functioning and life-goal attainment.

A mindfulness view of Yisel’s
anxiety symptoms would take into consideration of her insufficient attention to
the present moment as well as a lack of self-control and stability toward her
experience. Since Yisel is constantly unable to focus on her responsibilities
and engages in delinquent behaviors, this approach would focus on the lack of
equanimity toward Yisel’s experience. In addition to analyzing the signs that
Yisel is frequently passing up valued activities and having muddied reactions,
the mindfulness approach would also look for Yisel’s feelings that interfere
with her daily activities such as academic performance, sleeping patterns and
relationships. Since it is reported that Yisel has no motivation and repeatedly
says that she feels like “she will never be good enough” and her parents “will
be disappointed in her” if she doesn’t fulfill their expectations, it is important
to note her feelings where she seems increasingly stressed and frazzled. Yisel
is also feeling disconnected and constrained in life where it seems like she
does not have freedom or flexibility. For instance, according to Karekla,
Forsyth, and Kelly (2004) emotional avoidance is more predictive of panic
responses than other psychological risk factors such as anxiety sensitivity,
even in healthy individuals. Since Yisel is also suffering from nightmares, it
would be ideal to integrate mindfulness thinking and training for Yisel to understand
why she is having perpetual dreams that are haunting her. Moreover, through
further therapy and the development of ACT and mindfulness therapy, Yisel may begin
to have a greater insight for what is actually motivating her to behave in
certain ways. Yisel will also gain a deeper understanding as to why these
situations elicit what may seem like exaggerated emotional responses.

It would be ideal to look for
themes that would give an insight to current predicaments of Yisel. She is
often dwelling on her current failures and further avoiding the reality of her
situation in which these fixations could have only served to worsen her anxiety
by creating more basic mistakes. In order to treat Yisel’s anxiety disorder, new
behavioral therapies are needed to emphasize empowerment and increase skills
and behavioral repertoires that must be used in many contexts (Hayes, 2004). I
decided that Yisel should meet with a therapist for an hour and a half, once a
week for 12 weeks, with one follow-up session every three months as a post
treatment would be ideal. Each session would be roughly divided into four parts
where concepts of acceptance, mindfulness and values are interwoven into all
sessions. The first step, and one of the most crucial, is to begin with a
mindfulness exercise in which a popular exercise, the Body Scan (Kabat-Zinn,
2005) will be introduced. This is adapted from a mindfulness meditation program
from Jon Kabat-Zinn (2005) where Yisel will begin by bringing awareness to the
breath and body by resting on the floor, lying on her back with palms facing up.
The practitioner explains to Yisel to notice the rhythm, and the experience of
breathing in and expelling out. Then, guides attention to the body next where
Yisel will be instructed to bring her awareness to the parts if her body that
tingle, sore or feel intensely heavy or light. The Body Scan runs through each
part of the body and Yisel will pay special attention to the sensations that
arise in each part. Lastly, she will be given a definition of mindfulness which
is “paying attention in a particular way: on purpose, in the present moment,
and nonjudgmentally” (Kabat-Zinn, 1994). By practicing this exercise, Yisel
will be able to develop the capacity to observe her sensations and come to see
from her experience that she does not have to struggle with thoughts, feelings
and forcing them to be different. Additionally, this mindfulness exercise will
provide her the opportunity to reconnect her body and mind, which play a
fundamental role in the experience and expression of her emotions.

Furthermore, many sessions that
integrate some themes of ACT will be integrated in the treatment which use
metaphors and experiential exercises. One of the themes of ACT is to introduce
values and goals in life. In this exercise, Yisel would be encouraged to think
about what she wants to do with her life, not what she does not want to have or
feel. By helping Yisel stand for in key life domains such as education, family,
career, health, and leisure, this re-orientation will help guide and motivate
her as she moves through life. There will be 20-minute Values Writing
Assignments where she writes how her anxiety interferes with relationships
(family, friends, partner) and work, education, and household management. She
explores her deepest thoughts and emotions about the topics, and identifies
obstacles that prevent her from living consistently with values. She then is to
answer prompts where she will be able to reflect in making a commitment to a
values-consistent life, such as “what is the importance of the values you have
chosen? What do they mean to you?” or “what positive and negative reactions
come up when you think about making a commitment to change?” The therapist will
later use behavioral activation worksheets and additional experiential
worksheets to define more specific goals that lead Yisel in the direction of
those values. In this way, she can identify what is truly important for her to
pursue in her life. Returning the mind to the present time and place will help
Yisel gain insight into her emotions and behaviors, allowing greater
self-regulation.

Additionally, as an alternative
behavior to experiential avoidance, ACT can also aim to teach acceptance for
Yisel. According to Hayes et al. (2006), acceptance involves “the active and
aware embrace of those private events occasioned by one’s history without
unnecessary attempts to change their frequency or form, especially when doing
so would cause psychological harm.” For this exercise, Yisel is to make full
contact with the experience of anxiety and pay close attention to a single
focus, and learn to allow specific anxiety-related thoughts and sensations come
and go without trying to adjust them. The goal of this approach would be to
increase willingness to experience discomfort and to have internal experiences
for Yisel. Acceptance is closely related to willingness and according to Luoma,
Hayes, and Walser (2007) willingness is a skill to be learned, not a concept or
a feeling. Therefore, Yisel will be invited to be open to the whole experience
of anxiety and making a choice to experience anxiety for what it is; a
collection of sensations, feelings, thoughts, and images (Luoma, Hayes, &
Walser, 2007). In this sense, willingness is the opposite of resistor and
avoidance and a major target in this treatment plan designed for Yisel. The
therapist’s role here would be to teach techniques and coach Yisel in their use
in a warm and nonjudgmental way that will help her function and feel better in
a reality-oriented setting. The therapist should also be serving as a model of
mindful living and should devote much time to teach Yisel to move with barriers
by helping her to apply mindful observation and other skills when faced with
anxiety-related discomfort. Likewise, both Yisel and the therapist should
specify concreate and achievable goals and build a sincere rapport between
themselves. It is also crucial for the therapist to help Yisel make commitments
to start engaging in actions that are in agreement with the values and outcomes
of the treatment.

However, as the “third wave”
approach has moved into the mainstream, a variety of criticisms have been
discussed within the academic community. Corrigan (2001) argued that ACT has
been developed ahead of the data, which has been an overly-hyped claim from
many critiques. However, according to Herbert (2005), director of the Ph.D.
program, in Clinical Psychology of Drexel University argued that evidential
warrant of specific claims must be examined in his PowerPoint Presentation of
Addressing the Criticisms of ACT. He asserted that some critics are “clearly
unaware of the data that exist” and do not generally compare specific claims
with evidence. Moreover, many radical behaviorists have criticized that ACT
seeks “undue influence” according to Herbert (2005). However, he argued that
there are ethical issues surrounding the limits of informed consent that are
significant cultural values and that this must be decided independent of
science by itself, like all values. Herbert therefore suggested to participate
in the “broader public ethical dialogue” rather than to restrain science for
arguing that ACT is just a technology. Those with minimal familiarity with ACT
have also argued that this form of therapy offers “nothing new”. While it is
true that ACT is just under 35 years old (Hayes, 2008), Hayes (2008) and
Herbert (2005) both argued that since many (though not all) techniques and
strategies are “indeed openly borrowed” and therefore ACT is not new. They
claimed that the organizing model, the close link with theory, a research
program, and philosophy are what is new in the acceptance and commitment
therapy. It has also been argued that ACT works only with the “well-educated”
and seeks ridiculously high goals, and thus make exaggerated predictions. However,
Hayes (2008) argued that this criticism only comes because the theory can be
difficult to understand. He further affirmed that there are many trials that
indicate ACT is useful for those who are “poor, uneducated, and intellectually
disabled” (Hayes, 2008) and that ACT “does not teach theory to the client, but
do therapy”, and that is what is different. In conclusion, even though there
have been criticisms on the lack of methodological limitations for ACT, it can
be counter argued that these are based on ignorance, misunderstanding, and
those in reaction to challenge the status quo.

Nonetheless, ACT and
mindfulness-based therapy, which are the most representative therapies of the
“third wave” of behavior therapy reveal strengths that can be extremely
valuable as a psychological intervention. In contrast to traditional CBT which
links thoughts, feelings and behavior, the “third wave” approach focus
primarily on the function of cognitions, specifically thought suppression and
experiential avoidance. This targets the situation or trigger that generate the
emotional response, encouraging the cognitive appraisal, and converging on
changing the content of cognitions (Hofmann, 2008). Asking “why” can leave many
clients helpless, however, ACT invites clients to accept the reality and work
with what they have. This approach uncovers strengths as it encourages patients
to try to develop equanimity – “an attitude of curiosity, openness, and acceptance”
or “this too shall pass” to current experience, which effectively reduces
suffering. While CBT methods often deliver an experiential manner, third wave
approaches use strategies such as acceptance of undesirable thoughts and
feelings and mindfulness exercises to stimulate change in the thinking process
in a didactic manner (Hayes, 2004). Furthermore, Hayes (2008) argue that ACT is
culturally applicable and internationally effective for clients from diverse
backgrounds. He claimed that there are ACT studies from 15 countries including
Asia, Africa, and the Middle East and successful studies have been done with
poor urban black populations (Hayes, 2008). On the whole, mindfulness and
acceptance and commitment therapy therefore plan a crucial role in helping to
reduce anxiety and depressive symptoms as they offer alternative therapeutic
goals that seem more flexible, meaningful, and effective. Mindfulness and
acceptance and commitment therapy offer patients a path out of a suffering by
helping them choose to live the life based on what matters to them the most. It
is an extensive and a revolutionary approach to living a fulfilling and more
rewarding life.