Acceptance and Commitment Therapy for

Parents

Whittingham, K., Sheffield, J. & Sofronoff,

K. The University of Queensland
Purpose The following program is an Acceptance and Commitment
Therapy stress management intervention, specifically targeting parents of
children with developmental disabilities. It is well understood that parents
of children with developmental disabilities experience high levels of stress.
The intervention is presented as a 4 hour intervention delivered in 2
sessions (of 2 hours each) with homework. This intervention, as written,
was trialed along with Stepping Stones Triple P for families of children with
Cerebral Palsy and families of children with Acquired Brain Injuries and
found to be effective. Results from the RCT of Stepping Stones Triple P
and Acceptance and Commitment Therapy for families of children with
Cerebral Palsy showed additive benefits of Acceptance and Commitment
Therapy above and beyond conventional parenting interventions. For more
information, consult the relevant publications. The intervention could be
adapted to other high-risk groups of parents.

Relevant Publications Whittingham, K., Sanders, M., McKinlay, L. &

Boyd, R.N. (2014). Interventions to Reduce Behavioral Problems in
Children with Cerebral Palsy: An RCT. Pediatrics. Accepted 14/02/2014
Epub ahead of print. Brown, F., Whittingham, K., Boyd R., McKinlay, L. &
Sofronoff, K. (in press) Improving child and parenting outcomes following
paediatric acquired brain injury: A randomised controlled trial of Stepping
Stones Triple P plus Acceptance and Commitment Therapy. Journal of
Child Psychology and Psychiatry. Accepted 27/01/2014. Whittingham, K.,
Sanders, M.R., McKinlay, L. & Boyd, R.N. (2013) Stepping Stones Triple P
and Acceptance and Commitment Therapy for parents of childrenwith
cerebral palsy: Trial protocol. Brain Impairment. 14 (2), 270-280. Brown,
F., Whittingham, K., McKinlay, L., Boyd, R.N. & Sofronoff, K. (2013)
Efficacy of Stepping Stones Triple P plus a stress management adjunct for
parents of children with acquired brain injury: The protocol of a
randomized controlled trial. Brain Impairment. 14 (2), 253-269.

Enquires This workshop was prepared by Koa Whittingham, Jeanie

Sheffield and Kate Sofronoff. Please direct enquires to: Koa
Whittingham [email protected]
Sources

The content of this program is based on Acceptance and Commitment

Therapy as presented in: Hayes, S.C., Strosahl, K.D. & Wilson, K.G.
(2003) Acceptance and commitment therapy: an experiential approach to
behavior change. Guilford Press: New York.

ACT exercises and metaphors are adapted from: Hayes, S.C., Strosahl,
K.D. & Wilson, K.G. (2003) Acceptance and commitment therapy: an
experiential approach to behavior change. Guilford Press: New York.
Hayes (2005). Get out of your mind and into your life. New Harbinger
Publications: Oakland.

In addition, the mindfulness of the breath exercise and the mindfulness of

the thoughts exercise were adapted from: Segal, Z.V., Mark, J., Williams,
G., Teasdale, J.D. (2002). Mindfulness-based cognitive therapy for
depression: a new approach to preventing relapse. Guilford Press: New
York.
Session One Length: approximately 2 hours Purpose: The purpose of
session one is to provide a rationale for the intervention and the approach
of the intervention, to introduce Acceptance and Commitment Therapy, to
introduce the concept of struggle and to explain values. Summary:
✓ Housekeeping and introductions (10 minutes) ✓ Introduce ACT (10
minutes) ✓ Stress and parenting discussion (30 minutes) ✓ The
struggle (15 minutes) ✓ The passengers on the bus metaphor and role
play (15 minutes) ✓ Introduce values (15 minutes) ✓ Set homework
(10 minutes)

Housekeeping and Introductions (10 minutes) Address any

housekeeping such as the location of bathrooms. Therapists introduce
themselves. Depending upon group size, therapists may ask the parents
to introduce themselves as well. Therapists should provide name tags
before the session begins.

Introduce Acceptance and Commitment Therapy (10 minutes)

Introduce the concept of ACT using the battlefield metaphor. Prepare
the participants to experience something different.

“We know that parenting a child with a developmental disability [note:

discuss particular developmental disability as relevant] can be challenging
and one of the by-products of this is that parents of children with a
developmental disability experience a lot of stress. That is what we are
going to focus on for these first two sessions. After we’ve focussed on your
own stress we’ll begin to focus on parenting with Stepping Stones Triple P.
This stress management intervention is based in Acceptance and
Commitment Therapy or ACT which is a very different way of looking at
how you handle stress, not just the stress of being a parent of a child with
a developmental disability but the stress that is a part of life. You’ll be
pleased to know that Acceptance and Commitment Therapy has a growing
evidence base as a useful intervention for improving how people cope with
all kinds of stress. The ACT approach might seem a bit unusual to some of
you at first. ACT is quite different from traditional approaches to stress
such as relaxation and is probably quite different to what you usually think
of as managing stress. So I’m going to ask you to suspend
some initial judgements, to go with me on this for today, to try it out and to
see for yourself whether or not this different approach could be helpful for
you. I’m also going to ask you to be a bit patient. By the end of our two
sessions we’ll be getting down to the nitty-gritty of what you can actually
do. But because the approach is so different it is important that we all
clearly get the concepts right before we move on to the nitty-gritty stuff.
Does that make sense? So I keep telling you we’re doing something
different. Let me give you a glimpse of what I mean. Usually, our approach
to stress is to try to get rid of it. We think that the problem is that we are
stressed- if only we could be less stressed then we could really be a good
parent, or a wonderful partner, or really enjoy life. So we get into a real
battle with stress. We’ve probably all tried out lots different weapons to try
to win the battle with stress and sometimes we seem to win some ground
too. But the battle itself keeps going. It might seem like we have to keep
battling with stress everyday to keep on top of life. What you probably
thought you were going to get from us today was a bigger, better weapon.
Am I right? Something that could maybe destroy stress once and for all?
Well, that’s not what we’re going to do. We are going to learn a very
different move. We are going to learn how to walk away from the
battlefield.... That is probably sounding quite vague right now but as we go
through the day these concepts will become clearer and we’ll start to get to
the nitty-gritty of what you can do.”

Stress and parenting discussion (30 minutes) Therapists facilitate a

group discussion on the sources of stress in parenting a child with a
developmental disability [discuss the specific disability as relevant].
Therapists should make use of the whiteboard in creating this list.
Therapist discusses the battlefield metaphor again and facilitates a group
discussion on the “weapons” that the parents have already used in the
battle against stress. This is done with the aim of drawing out that these
“weapons” may help in the short term but none of them ultimately win the
battle, also many of them have costs. This is consistent with the ACT
concept of creative hopelessness and provides a rationale for the
workshop.

“Let’s start with a group discussion. Without turning this into just a whinge
session and making ourselves miserable; let’s discuss exactly what is
stressful about parenting a child with a developmental disability and what
kinds of stress you are experiencing. Any thoughts?” Therapist facilitates
the discussion and writes suggestions onto a whiteboard. If parents don’t
respond:
“I know from working with parents of children with developmental disability
some things they can report is that there is an extra burden of care, a need
to provide constant supervision, difficultly in transitions, a need to advocate
for your child [discuss as relevant to the specific disability]. I’ve found that
parents say that they’re experiencing worries about their child’s future,
sadness when their child isn’t able to do something physically. Is that what
you’re finding?” Therapist wraps up the discussion and focuses on the
battlefield metaphor again.
“So we can see from that short discussion you are experiencing stress and
that’s not surprising. I talked earlier about how we can get into a battle with
stress. You’ll notice that when we brainstorm about your stresses that
some of these things are aspects of your situation, like the fact that you
need to advocate for your child at school. Others are your own emotions,
thoughts, memories, like worries about your child’s future. When I’m talking
about the battle with stress I don’t mean the battles that you have out there
in the world for your child, or even changes that you choose to make in how
you live or what you do. I mean getting into a battle with your own stressful
thoughts, emotions and memories. Have any of you experienced that?
What kinds of weapons have you tried using to win the battle against
stress?” Therapist elicits some responses from participants and writes
suggestions on a white board. Therapist facilitates a discussion on the
workability of these weapons- do they work in the long-term? Are there
costs? “Do these weapons that you are talking about work?” “Some of
these weapons help you to win some ground in the battle against stress for
awhile, do they keep working in the long-term? Has anyone here
conquered stress once and for all?” “Are there any costs with these
weapons?” “Have you ever had a moment where you’ve realised that
you’ve been so focussed on the battle with stress that you aren’t being the
kind of parent that you want to be? Or living life as you want to live it in
another area of your life?” Therapist wraps up this exercise and leads into
metaphors on the struggle. “It is interesting isn’t it? It seems that battles
with our own thoughts, feelings and memories don’t quite work the same
way as battles with things out there in the world. Maybe the fact that you
haven’t won the battle against stress isn’t because you aren’t bright enough
or strong enough or not equipped with just the right weapon....maybe this is
exactly what a battle with stress looks like. Let’s look at this idea in more
detail by looking at some other struggles out there in the world that seem to
work the same way. There are a few other
situations in which there’s a hard-wired instinct to struggle harder but
where that’s exactly the wrong thing to do.”

The Struggle (15 minutes) The therapist introduces a metaphor or

several metaphors for the struggle. Here the therapist will discuss the
quicksand metaphor. The therapist may also illustrate the struggle with
other metaphors such as; getting caught in a rip, skiing, tug of war, or the
chinese finger trap metaphor. This should be done as needed for the group
depending upon the understanding of the parents. For each metaphor
introduced the therapist relates it back to the workability of the struggle.
“First of all let’s talk about quicksand. Are we all familiar with quicksand?
Probably no one here has seen quicksand in real life but we’ve all probably
seen it on cartoons and movies? Good- now imagine what you’d do if you
actually got caught in quicksand. What would your basic instincts tell you to
do? Absolutely- you’d just want to leap straight back out of the quicksand
as fast as you could, you’d struggle. Actually, that’s the last thing that you
should do. Do you know what happens if you try to get out of quicksand
like that? That’s right- you get caught even more in the quicksand and you
sink deeper into it. Does anyone know what you should do if you get
caught in quicksand? That’s right you need to relax, stop struggling and lie
back into the quicksand so that more of your body is in contact with the
quicksand. If you do that you’ll float to the top and you can stay there safely
until help arrives. Now- this isn’t really about the quicksand. This is just an
example of how sometimes continuing to struggle is the very last thing we
need to be doing. ” The therapist helps parents to understand that
struggling with thoughts, feelings and memories is like struggling with
quicksand (or a rip etc.) by using specific examples for thoughts, feelings
and memories. The therapist should discuss some version of; changing a
picture vs changing a memory, do not think of a pink elephant and feelings
multiply. “Our struggle with thoughts, feelings and memories is exactly like
this. It often it simply doesn’t work. Imagine for example, that when you go
home today you see a picture in your lounge room and you decide that you
now hate that picture and you never want to see it again. Could you get rid
of the picture? Sure. What if instead you remembered something and you
decided that you now hate that memory you never want to see it again.
Could you get rid of the memory? No... So our thoughts, feelings and
memories aren’t quite the same as the stuff out there in the world. What
about your thoughts? In a moment I’m going to say the word ‘go’ and when
I do I want you to not think of a pink elephant. Don’t think of the long trunk,
the big floppy ears, and the large legs,
don’t think of a pale pink elephant, don’t think of a hot pink elephant.
Ready? Okay, now, go.... (pause)... did anyone manage that? Can you see
the problem? The only way to be certain that you aren’t thinking about a
pink elephant is to check, in other words to think ‘ah good, I haven’t
thought of a pink elephant...’ but straight away you are thinking of pink
elephants again. What about emotions then? There’s a good reason why
struggling with our own emotions doesn’t work. Say, you start by feeling
anxious, but you don’t won’t to feel anxious and you start to push that
away. Maybe now you also feel angry at yourself for feeling anxious. Then,
maybe you feel sad because you are so angry at yourself. So emotions
tend to grow an multiply when we struggle with them.” Therapist facilitates
a small group discussion on the Struggle to ensure that the concept is
understood. Therapist ensures the parents understand that this is about
the struggle with thoughts, emotions and memories not about battling for
their child. “What are some of the thoughts, emotions and memories that
you really struggle with? Are there any particular thoughts that are really
sticky and that you get caught up in? Or emotions that you just want to
push away? Remember, you’ll also have struggles and stresses that you
can act on in your life. Letting go of struggling with our own thoughts,
feelings and memories gives us the energy and focus to put into changing
what we can change. ”

Passengers on the Bus Metaphor (15 minutes) Therapist introduces the

passengers on the bus metaphor and facilitates the parents acting this
metaphor out in pairs. In each pair both parents take turns in playing the
role of the driver and the passenger. As the driver they try both struggling
with the passenger and accepting the passenger. The therapist should act
this out with a particular parent in front of the group first to ensure that all
parents understand the task. The acting out of this metaphor is based on
the exercise taking a walk with the mind. This exercise should give parents
a glimpse of what giving up the struggle could look like. “So what’s the
alternative? It is like you are a bus driver and the bus is your life. You want
to take your bus west, that’s the direction you’d like to go. Our thoughts,
feelings and memories are like passengers on our bus. Sometimes the
passengers are nice and polite; we don’t mind taking these passengers
along for the ride! Other times the passengers are nasty. What kinds of
nasty thoughts can pop into our heads? What kinds of negative feelings
might we feel? The struggle that we get into is with these passengers. We
start arguing with them, trying to kick them off the bus or we may even
strike a deal with them. We may for example, strike a deal with the
passenger guilt that says
you’ll stop taking the bus west and instead take the bus wherever guilt
wants to go as long as guilt sits up the back and stays quiet. Can you relate
to that? But the thing is while we’re busy arguing with the passengers,
convincing them to go away or striking deals what aren’t we doing? We’ve
taken our hands off the wheel. We’re no longer driving the bus. So can we
instead acknowledge the passengers and take them along for the ride with
our eyes on the road and our focus on driving the bus? We’re going to act
this metaphor out so that we can really see what struggling with
passengers vs accepting passengers might look like. For this next exercise
you’ll need to get into pairs. You are both going to have a turn at being the
driver and the passenger. When you are the passenger your goal is to
voice lots of nasty or distracting thoughts. When you are the driver first of
all try struggling with your passenger by arguing back. Then try accepting
the passenger and focussing instead on doing what you want to do. Before
we all act it out I’m going to act it out for you so that you can see exactly
what I mean. Can I please have a volunteer? Therapist acts out both roles
ensuring that everyone understands the exercise. The therapist then gives
the pairs several minutes in each role. Therapist winds up the exercise and
makes a quick comment that this is not about whether the thoughts are
true or false. If some of the parents are confused about this or ask
questions the therapist can spend longer on this point discussing specific
examples of true thoughts that it isn’t helpful to struggle with like “I’m going
to die”. “So the more the driver struggled with the thoughts the more
difficult it was to keep focussing on values and driving West. It is important
to realise that this isn’t about whether thoughts are true or false. It is about
the fact that they are just thoughts and whether or not they are true or false
it isn’t very helpful to struggle with them.”

Introducing Values (15 minutes) Therapists introduce the concept of

values and distinguish values from goals using the metaphor of going
West. Therapists facilitate a group discussion on the values that
participants have as parents. If the participants suggest a goal therapists
remind them of the difference between goals and values and elicit the
underlying goal. “So far we’ve been focussing on letting go of the struggle,
walking away from the battle, letting the passengers come along for the
ride. Now I’d like to focus on where you’d like to drive your bus. Notice that
just like a country we have limited resources. When a country is at war
much of that country’s resources have to go into that war. But when a
country is at peace the country can put their resources into other things-
education, health, trade, arts programs. So a
big part of walking away from the battle with stress is; what are you going
to spend your resources on instead? Your homework for next session will
be to think about this question. It is important here to distinguish between
values and goals. A value is a direction in which you want your life to go-
like heading West whereas goals are places you might walk to on the way.
A goal is something you can complete. If you say you want to walk to the
next corner you can walk there, reach it and it is done. You can’t complete
heading West. It is never finished. In the same way “being a loving parent”
is never finished. It doesn’t matter how many hugs you’ve given your child
you can never say that you’ve finished being a loving parent. There’s
always more to do. This distinction between values and goals is an
important one because we can get very caught up with our goals and lose
sight of the underlying values which is really what it is all about.
Sometimes we have particular goals and our circumstances change or
sometimes realistically our goals need to be very small because that’s all
we can do right at that moment. If we are just looking at our goals we can
become discouraged when this happens. If our focus is on values it is
easier to adapt. What I want you to think about is what values you have,
the general direction in which you’d like your life to move. Group
Discussion: Parenting Values Therapist facilitates a short discussion about
parenting values to ensure that the parents understand the task. “What
kinds of values do you have around parenting. It may help cast your mind
back to the days before you had children, perhaps even think of times like
when you were trying to fall pregnant, during your pregnancy or shortly
after your child was born. What kind of parent did you want to be? What
kind of parent do you want to be now?”

Setting Homework: Values Worksheet (10 minutes) Therapist

completing the values worksheet for homework. “To help you think through
your values in various areas of your life please complete the values
worksheet for homework. You’ll notice the values worksheet has different
life areas listed as a space for writing your values in each. You’ll also
notice two spaces for putting your ratings. For each life area rate how
important your values in this area are on a scale of 1-10 with 1 being not at
all and 10 being very important. Also, rate how well you are living out your
values in this area on a scale of 1-10 with 1 being not at all and 10 being
living your values out completely. The purposes of these ratings is so that
you can find which areas of your life you’d like to focus on. We all have
some areas of life that are more important to us than others. Also, it is
important to find the areas of your life in which there’s a difference between
how important you
think the area is and how much you are living your values in the area.
We’ll discuss this further next week.”

Session 2 Length: approximately two hours Purpose: The purpose of

session two is to introduce mindfulness and cognitive defusion. In addition,
values will be discussed with goals created for the next week. Summary:
✓ Introducing mindfulness (10 minutes) ✓ Mindfulness of the breath
exercise (10 minutes) and debrief (10
minutes) ✓ Thoughts are just thoughts (10 minutes) ✓ Leaves on the
stream exercise (10 minutes) and debrief (10 minutes) ✓ Mindfulness of the
emotions exercise (10 minutes) and debrief (10
 minutes) ✓ Putting values into action (30
minutes) ✓ Setting homework (10 minutes)

Introducing Mindfulness (10 minutes) Therapist introduces the concept

of mindfulness and leads into the first mindfulness exercise- mindfulness of
the breath. “In our last session we looked at the problems of struggling with
feelings, thoughts and memories. We saw that when the driver was able to
notice that the passengers were there and keep their own attention
focussed on the road, on heading West then life seemed a lot better for the
driver- they were able to head West! Now you might be wondering, how do
I do that in my life? Maybe you’re even thinking that some of your thoughts
and feelings are really nasty and how are you going to be able to just notice
them and keep your eyes on the road? Well, the ability to do that, to just
notice thoughts and feelings and keep your eyes on the road is a particular
skill. That skill is called mindfulness. Mindfulness is the skill of being able to
notice that your attention has wandered, maybe to a thought or a feeling
and being able to put that attention back onto whatever we want our
attention to be on. Mindfulness also means that we do this without judging
ourselves, without getting trapped into fighting with the passengers and
being able to accept whatever passengers come along for the ride.
Mindfulness is an experiential skill- it is something that you do. Just like any
other skill I can’t just tell you how. I can give you some good instructions
and some feedback on how you’re going but you’re going to need to
practice it. So it is like learning to bake a cake or learning to swim I can
give
you a great explanation of how to swim but that doesn’t mean you can
actually do it. You need to try it out and practice and practice until it clicks.
Mindfulness is like that and that’s why we’re actually going to do some
mindfulness, so you can try it out for yourselves and get some feedback
from me. Then, if you want to build the skill yourselves you can practice
later on at home too. Mindfulness may seem like a simple skill but it is
amazing how much we just don’t live mindfully. We spend a lot of our time
not living in the present, getting caught up in thoughts about the past and
thoughts about the future. Can anyone think of an example of when you’ve
been doing a task and you’ve realised you’re not actually engaged in it
instead you are absorbed in your own thoughts? Good. Let’s get a taste of
mindfulness with a mindfulness of the breath exercise. Mindfulness
exercises usually involve bringing your attention to a specific aspect of your
environment like your breathing or simply keeping your attention broadly in
the here and now. A mindfulness of the breath exercise is a good place to
start and an excellent way to practice mindfulness because we carry our
breathing around with us wherever we go. So once we learn mindfulness of
the breath it is easy to practice during the day by bringing our attention
back to our breath every now and then.”

Mindfulness of the breath exercise (10 minutes) Therapist talks the

parents through a mindfulness of the breath exercise. The therapist takes
their time following the script allowing parents time to complete the
exercise. “So let’s start the exercise. First of all, settle into a comfortable
sitting position. Allow your back to adopt an upright and comfortable
position. If sitting on a chair, place your feet flat on the floor, with your legs
uncrossed. You may like to close your eyes. Bring your awareness to the
level of physical sensations by focusing your attention on the sensations of
touch and pressure in your body where it makes contact with the floor and
whatever you are sitting on. Spend a moment just exploring these
sensations. Now bring your awareness to the changing patterns of physical
sensations in the lower abdomen as the breath moves in and out of your
body. Focus your awareness in the sensations of slight stretching as the
abdominal wall rises with each in- breath, and of gently deflation as it falls
with each out-breath. As best you can, follow with your awareness the
changing physical sensations in the lower abdomen all the way through as
the breath enters your body on the in-breath and all the way through as the
breath leaves your body on the out-breath, perhaps noticing the slight
pauses between one in-breath and the following out-breath, and between
one out-breath and the following in-breath. There is no need to try and
control the breathing in any way – simply let the breath
breathe itself. As best you can, also bring this attitude of allowing to the
rest of your experience. There is nothing to be fixed, no particular state to
be achieved. As best you can, simply allow your experience to be your
experience, without needing it to be other than it is. Sooner or later (usually
sooner), your mind will wander away from the focus on the breath in the
lower abdomen to thoughts, planning, daydreams, drifting along –
whatever. This is perfectly ok – it’s simply what minds do. It is not a
mistake or a failure. When you notice that your awareness is no longer on
the breath, then congratulate yourself – you have come back and are once
more aware of your experience! You may want to acknowledge briefly
where the mind has been (‘Ah, there’s thinking!’). Then, gently escort the
awareness back to a focus on the changing patterns of physical sensations
in the lower abdomen, renewing the intention to pay attention to the
ongoing in-breath or out-breath, whichever you find. However often you
notice that the mind has wandered (and this will quite likely happen over
and over and over again), as best you can, congratulate yourself each time
on reconnecting with your experience in the moment, gently escorting the
attention back to the breath, and simply resume following in awareness the
changing pattern of physical sensations that come with each in-breath and
out-breath. As best you can, bring a quality of kindness to your awareness,
perhaps seeing the repeated wanderings of the mind as opportunities to
bring patience and gentle curiosity to your experience. Continue with the
practice for a time reminding yourself from time to time that the intention is
simply to be aware of your experience in each moment, as best you can,
using the breath as an anchor to gently reconnect with the here and now
each time you notice that your mind has wandered and is no longer down
in the abdomen, following the breath. Now we are coming to the end of the
exercise so I’ll ask to, when you are ready return your attention to what is
happening in this room. Perhaps start by noticing the sounds around you.
When you are ready open your eyes and stretch your body if you feel the
need.”

Mindfulness of the breath debriefing (10 minutes) Therapist de-briefs

the mindfulness of the breath exercise with a group discussion. If parents
mention that the exercise made them feel relaxed the therapist needs to
emphasize that this is a common side-effect of mindfulness but not the
goal. The goal is not to get rid of stress. Therapist also emphasizes that
the goal is not to not think- the goal is to be aware of the thinking and bring
one’s attention back to the breath. If that needs to be done a hundred
times that is okay.
“Let’s talk about what that was like, anyone want to share their
experiences? Was it difficult to keep your attention on your breath? Do you
usually notice your breathing like that? As I said at the beginning of this
session mindfulness is a skill and just like any skills you’ll get better the
more that you practice. You can practice mindfulness by doing any of the
exercises that we covered today yourselves at home. You can also
practice mindfulness in your daily life by simply deliberately keeping your
attention on whatever task you are doing whether it is doing the dishes, or
ironing or walking to the bus-stop. The more you practice the better you’ll
become at mindfulness and the easier you’ll find it to stay mindful even in
stressful situations.”

Thoughts are just thoughts (10 minutes) Therapist introduces cognitive

defusion exercises and ensures that the parents get the central point that
thoughts are just thoughts.
“You might have found during the mindfulness exercise that some of your
thoughts were particularly sticky and hard to let go of. Thoughts are often
the passengers that we get caught up arguing with. It may seem like we’ve
got to win the argument, to prove the thought wrong or to figure out what’s
true before we can return to driving the bus. We’re going to do some
exercises with our thoughts now and explore the idea that thoughts are just
thoughts. For these exercises I’m going to ask you to think of a particularly
sticky, nasty thought that you have, something like “I’m just worthless”, “I’m
a bad parent”. Take a moment now to think of it. Firstly, let it catch you. Try
to really buy into the thought. Repeat the thought in your mind. Has
everyone got it? Now I want to you repeat the thought but start with “I’m
noticing that I’m having the thought that....” So instead of saying “I’m just
worthless” you might say, “I’m noticing that I’m having the thought that I’m
just worthless”. What do you notice?” Therapist elicits that the thought is
less sticky. There’s distance between the person and the thought. “Let’s try
another. Again, start by thinking the sticky thought and take a moment to
really buy into it. Repeat the thought in your mind. Now repeat the thought
in a silly voice like the voice of a cartoon character. What do you notice?”
“Let’s try another. Again, start by thinking the sticky thought and take a
moment to really buy into it. Repeat the thought in your mind. Now imagine
that you are watching your thoughts from a distance. If you like you can
visualise that the thought is a leaf floating down a stream in front of you or
a cloud floating across the sky, or that it is scrolling across a computer
screen. What do you notice?”
“These are all strategies that people find helpful to get some distance from
their thoughts and to see their thoughts for what they are just thoughts.
There are other strategies you might like to try such as singing your
thought or imagining that your thoughts are a radio. You might find some of
these strategies better than others or even come up with your own and
that’s fine. The important thing is to realise that thoughts are just thoughts.
We don’t need to act on them, or react to them or prove them true or false.
It is like having a radio on, tuned to a station that plays music you don’t
always like and you can’t switch the radio off. You could sit near the radio
all day listening intently and becoming distressed about the music. Or you
could get on with cooking dinner or being with your children and just let the
radio be in the background, without giving your attention to it.”

Leaves on the Stream Exercise (10 minutes) Therapist guides the

parents through the leaves on the stream exercise. The therapist takes
their time following the script allowing parents time to complete the
exercise. “We can also specifically practice being mindful of our thoughts.
Let’s try that now. Let’s start by getting into a comfortable posture. If you
wish to you can close your eyes. Begin to bring the spotlight of your
attention to focus on the sensations in your body. You might like to spend a
few moments just paying attention to your breathing. When you are ready
we are going to watch our thoughts. You might like to imagine that you are
sitting on the bank of a stream. You are sitting at the side of the stream
watching the stream’s flow. Your thoughts are like leaves being carried
down the river. Every so often you notice a thought arise, like a leaf at the
top of the stream and that thought flows through your mind for while and
then disappears again. See if you can imagine your thoughts as leaves on
the stream. You can also imagine that your thoughts are like cars driving
past or clouds in the sky or even pictures on a TV screen. If you find the
visual is not helpful that is okay. You don’t need to focus on it. The
important thing is to watch your thoughts. You might notice that some
thoughts keep coming back. That’s okay. Just keep noticing the thought as
a leaf on the stream Notice the thought arises, flows through your mind for
awhile then disappears again. You might also find that you have thoughts
about this exercise, maybe thoughts like ‘this is boring’ or ‘this is difficult’.
Just notice these thoughts too are thoughts. Stay watching your thoughts
as best you can. Every so often you might notice that you get sucked into
your thoughts and that the thoughts carry you away with the. If this
happens, that is okay. Congratulate yourself on becoming aware of this
even if it happens a hundred times and pull yourself out of your thoughts
and back
watching them. We’re coming to the end of the exercise so I want you to
put your attention back on your breath for a few moments. Now bring your
attention to the sounds around you in the room. When you are ready,
open your eyes and if you feel the need have a stretch.”

Mindfulness of thoughts debriefing (10 minutes) Therapist debriefs the

mindfulness of thoughts emotions exercise with a group discussion.
Therapist emphasizes that the goal is to be aware of when you get sucked
in to the river and to be able to return to watching your thoughts. “Let’s talk
about what that was like, anyone want to share their experiences?” “Did
anyone get caught up in their thoughts and sucked down the stream?”
“This can be really tricky at times. Notice that thoughts are just thoughts.
We don’t necessarily have to pay attention to them, to act on them or
react to them. Instead, we can just let the thoughts come and go.”

Mindfulness of emotions exercise (10 minutes) Therapist talks the

parents through a mindfulness of emotions exercise. The therapist takes
their time following the script allowing parents time to complete the
exercise. “Now that we’ve got a sense of what mindfulness is let’s try
another mindfulness exercise. Let’s try a mindfulness of emotions exercise.
In this exercise I’m going to ask you to bring up a unpleasant emotion and
we’re going to practice being mindful of it. It may help to think about a
particular experience such as how you felt after a difficult interaction with a
teacher or an argument with a family member. Okay, ready to start? Again,
let’s being by getting into a comfortable posture. If you wish to you can
close your eyes. Begin to bring the spotlight of your attention to focus on
the sensations in your body. You might like to spend a few moments just
paying attention to your breathing. Now I want you to bring to mind a
particular unpleasant emotion. To do this you may need to think about
something specific that’s happened to you such as a difficult interaction
with a teacher or an argument with a family member. I’ll give you a moment
to do this now. Now scan your body with your attention and find the areas
in which the emotion feels the most intense or troublesome to you. Is it the
feeling in your stomach? Or maybe a tightness in your shoulders and neck?
Or perhaps a dull ache in your head? Focus in on the most bothersome or
intense sensation. Pretend that you are a curious scientist, or an
adventurous explorer who is interested in feeling everything that is involved
in this sensation. Start exploring the emotion by imagining that the
sensations are an object. If the sensations were an object;
What colour would it be? What temperature would it be? How would it feel
to touch? Would it be moving or stationary? Would it be light or dense?
Approach the emotion with a genuine sense of curiosity and acceptance.
You might like to continue exploring the emotion by imagining that the
emotion is a creature. If the emotion were a creature; What would it look
like? How would it feel to touch? What would it be doing? Would it be
moving or stationary? Would it be light or heavy? At this point you may
have found that thoughts have arisen in your mind about the emotion. Your
mind may say something like, “I don’t like this feeling”, or “I don’t want to
feel this”. Alternatively, thoughts about something unrelated to the emotion
may pop into your head. If so, simply observe the thoughts arise and gently
guide your attention back to mindfully exploring the emotion. If you find
yourself experiencing a strong sense of resistance to exploring the emotion
then imagine that this feeling of resistance is itself an object or a creature
and explore this emotion with the same sense of curiosity and acceptance.
Try to cultivate a sense of acceptance and kindness towards the emotion-
creature. Consider, it may be ugly or aggressive but it has got nowhere
else to go. Breathe in and around the emotion-creature or emotion- object.
Focus upon your breath gently swirling around the emotion. With each in-
breath feel yourself getting bigger and making room for the emotion. Notice
that you are bigger than the emotion. Try, as best you can, to make room
for the emotion. This doesn’t mean you have to like it, or want it to be
there. It just means making room for it and allowing it to be there. Spend
some moments just sitting with the emotion. Now we are coming to the end
of the exercise so spend a few moments paying attention to your breath.
And now pay attention to the sounds in the room. And when you are ready
open your eyes and stretch if you need to.”

Mindfulness of emotions debriefing (10 minutes) Therapist de-briefs

the mindfulness of emotions exercise with a group discussion. If parents
mention that the exercise made the emotion go away the therapist needs
to emphasize that this can be a side-effect but it cannot be the goal. The
goal is not to get rid of stress. Therapist also emphasizes that being
mindful of emotions puts you back into control not the emotions.
“Let’s talk about what that was like, anyone want to share their
experiences?” “Notice that this skill of being able to be mindful of emotions
means that you are in control- not your emotions. Often we get locked into
particular ways of behaving just to get rid of painful emotions- we
negotiate with the passengers on the bus! But if we can just stay present
with our emotions, let the passengers come along for the ride no matter
how ugly that gives the choice back to us. We can keep going in the
direction that we want to go in.”

Putting values into action (30 minutes) Therapist returns to values, the
concept of making a plan and the concept of acts- steps towards their
value. The therapist emphasizes the importance of small acts. “For
homework we completed the values worksheet. We’re going to return to
looking at values now. Did anyone have any questions about the values
worksheet first?” “Now we want go back to your values and ask; what could
I actually do to move closer to my values? What actions could I take? Pick
a life domain that you’ve rated as important but where you also feel you
aren’t living out your values fully. I’ll give you a moment shortly to
brainstorm and come up with some actions that you could take. You may
think of some bigger actions and that’s fine. You might decide that there
are skills that you don’t have that you’ll need to learn or extra information
that you need to gain. That’s fine too, put that down as well. We don’t want
a list of just bigger acts though. We also want to make sure there are
plenty of small, tiny steps on this list as well. So please put down actions
that you can do every day as well as actions that you might do only once a
year. You want to have lots of actions that you can incorporate into your life
on a day to day basis. You can think of this a bit like stocking your kitchen
pantry. You don’t want a kitchen pantry filled with only food that requires a
lot of time and energy to cook you want it to be stocked with some easy
meals and ready-made snacks as well! So your plan needs to have bigger
acts for the days when you have the time and energy to invest as well as
smaller acts that you can do anytime. It might help you to come up with
these smaller acts to think; what is the smallest thing I could do? When you
write down these acts please also write down any barriers you can see to
you carrying out these acts. You might notice that there are two types of
barriers- one type of barrier would be a practical barrier. So you might
realise that you need some extra information or to learn a new skill. We’ll
do some problem-solving together about these barriers. You might notice a
different type of barrier too- a thought, or a feeling or a memory might pop
up as well and tell you that they are a barrier. We’ve already learnt how to
not struggle
with our thoughts, feelings and memories and that is exactly what we are
going to practice if this happens. I’ll give you some time to work on this
alone first.” Therapist directs the parents to work alone initially, giving out
a sheet to write down acts, barriers and possible solutions.

Small group discussion Therapist directs the parents to get into small
groups and discuss their acts, barriers and possible solutions. “Now I want
you to get into small groups and discuss your acts, barriers and potential
solutions. This is an opportunity to pool ideas for acts as well as ideas for
solutions around barriers. You might find that as you hear what other
people have written down you want to add something new to your list.
That’s great, please do add it. You can also try to help each other to come
up with possible solutions to any barriers listed. Remember that there can
be two types of barriers. So think about whether the barrier is a practical
barrier that needs to be problem-solved or whether the barrier is a thought
or an emotion that you may need to let go of the struggle with.”

Group Discussion and debrief Therapist facilitates a group session on

the acts, barriers and possible solutions. “Let’s discuss the acts, barriers
and possible solutions as a group. What are some acts that you had listed?
And what were some barriers that you thought of? And solutions? Were
some barriers really thoughts and emotions?”

Setting homework “Your homework is to pick a small act that would

bring you closer to your values and do it this week. Remember pick a
small act, something you could easily do. Are there any questions?”

Closing the ACT Stress Management Intervention “This is the end of

the Stress Management aspect of our group. Next week we’ll begin
looking at parenting. Remember as you try this out in your life that you will
find that you’ll still get stuck in the battle from time to time, that you will
lose sight of your values from time to time. That is okay. The important
thing is to be able to recognise this and to be able to bring yourself back to
focussing on going in the direction that you want to go.”

Therapist distributes a summary sheet on the ACT component of

the intervention.
Appendix A: Parent
Worksheets
Actions Worksheet What could you do to move
closer to your values? Brainstorm and write down every idea you have whether or not it
is practical.
_____________________________________________________________________
______

_____________________________________________________________________
______
_____________________________________________________________________
______

_____________________________________________________________________
______

What are some small actions you could take to move closer to your values? Are there
any tiny steps you could easily make in your everyday life? What would be the
smallest step you could make closer to your values?
_____________________________________________________________________
______

_____________________________________________________________________
______

_____________________________________________________________________
______

_____________________________________________________________________
______

My Goals Goals Barriers Solutions

This week I will take the small step of:

_____________________________________________________________________
______

_____________________________________________________________________
______
Written by Koa Whittingham for the Stepping Stones Cerebral Palsy
Project

Values Worksheet:
Instructions

Values are what we want our lives to be about. A value is a direction in

which you want your life to go, like heading West. We never really finish
living out our values because there is always more to be done. Our values
provide the basis for the goals that we choose to act on day by day. But
whereas goals can be achieved or “crossed off” we never really finish
moving towards our values.

What do you want your life to be about? Deep down, what is

important to you? What do you want your life to stand for?

This values worksheet contains areas of life that are valued by some
people. Not everyone has the same values and this is not a test to see if
your values are “correct”. There’s no right or wrong answer. Under each
area of life there is space for you to brainstorm about your values in this
area. Try to focus on general life directions rather than specific goals. For
each area of life there’s also space to rate how important this life area is to
you on a scale of 1-10 (1 = not at all important, 10 = very important) and
how well you are currently living out your values in this area of your life on
a scale of 1-10 (1=not at all important, 10= very important). You may
notice that there is overlap between your values in different life areas. This
is fine.

Written by Koa Whittingham for the Stepping Stones Cerebral Palsy

 Project
You may find the following descriptions of the areas of life helpful as you
complete the worksheet: 1. Family. What sort of brother/sister, son/daughter,
uncle/aunt do you want to be?
What personal qualities would you like to bring to those relationships? What sort of
relationships would you like to build? How would you interact with others if you were
the ideal you in these relationships? 2. Marriage/couples/romantic. What sort of
partner would you like to be in a
romantic relationship? What personal qualities would you like to develop? What
sort of relationship would you like to build? How would you interact with your
partner if you were the ideal you in this relationship? 3. Parenting. What sort of
parent would you like to be? What sort of qualities would
you like to have? What sort of relationships would you like to build with your
children? How would you behave if you were the ideal you? 4.
Friends/social life. What sort of qualities would you like to bring to your
friendships? If you could be the best friend possible, how would you behave
towards your friends? What sort of friendships would you like to build? 5.
Career/employment. What do you value in your work? What would make it more
meaningful? What kind of worker would you like to be? If you were living up to your
own ideal standards, what personal qualities would you like to bring to your work?
What sort of work relations would you like to build? 6. Education/personal
growth. What do you value about learning, education, training or personal growth?
What new skills would you like to learn? What knowledge would you like to gain?
What further education appeals to you? What sort of student would you like to be?
What personal qualities would you like to apply? 7. Recreation/fun/leisure. What
sorts of hobbies sports, or leisure activities do you enjoy? How do you relax and
unwind? How do you have fun? What sorts of activities would you like to do? 8.
Spirituality. Whatever spirituality means to you is fine. It may be as simple as
communing with nature or as formal as participation in an organised religious group.
What is important to you in this area of your life? 9.
Citizenship/environment/community life. How would you like to contribute to your
community or environment, e.g. through volunteering, or recycling, or supporting a
group/charity/ political party? What sort of environments would you like to create at
home and at work? What environments would you like to spend more time in? 10.
Health/Physical well-being. What are your values related to maintaining your
physical well-being? How do you want to look after your health, with regard
to sleep, diet, exercise, smoking, alcohol etc? Why is this important?
Family Marriage/couples/romantic Parenting
Importance? (1-10) Importance? (1-10) Importance? (1-10) Living? (1-10)
Living? (1-10) Living? (1-10)

Friends/social life Career/employment Education/personal growth

Importance? (1-10) Importance? (1-10) Importance? (1-10) Living? (1-10)

Living? (1-10) Living? (1-10)

Recreation/fun/leisure Spirituality Citizenship

Importance? (1-10) Importance? (1-10) Importance? (1-10) Living? (1-10)

Living? (1-10) Living? (1-10)

Health/Physical Other notes about my values

Importance? (1-10)
Living? (1-10)

Appendix A: Parent
Handout
Acceptance and Commitment Therapy
 (ACT) for Parenting Stress
Stepping Away From the Battlefield Sometimes we can get stuck in a battle with
stress. It may seem like we need to fight this battle with stress in order to live the life
we want to live. Yet...no matter what weapon we use, even if we seem to gain some
ground, the battle just keeps going on. ACT is about approaching stress differently.
ACT is about stepping away from the battlefield. In the same way that a nation at
peace has more resources to spend on healthcare, education and arts programs
stepping away from the battle with stress will free you up to focus on living your life.

Accepting the Passengers It is like you involves noticing that our attention has
are the bus driver and the bus is your life. wandered and gently guiding it back. Like
You have a direction in which you’d like to any skill it improves with practice.
take the bus. Along the way passengers Practicing mindfulness of breathing is an
join you for the journey. These excellent way to practice mindfulness
passengers are your thoughts and because we carry our breathing around
feelings. Sometimes the passengers are with us wherever we go. To practice
nice and polite, others they are ugly, mindfulness of breathing sit in a
nasty and noisy! Sometimes they start comfortable, relaxed and upright position.
telling you how to drive the bus on in what Allow your attention to settle onto the
direction you should be going. When you physical sensations when you breathe.
start battling with your thoughts and You may prefer to focus on the
feelings you stop focussing on driving the sensations in your abdomen or your
bus. Sometimes you may even start nostrils. Whenever you notice that your
driving in the direction they want to go just attention has wandered congratulate
to get them to quieten down. Acceptance yourself for noticing this and gently guide
doesn’t mean that you need to like the your attention back to your breath. Try to
passengers or think that they are right (or bring a sense of curiosity to your
wrong!). Acceptance just means allowing experience as if you are really interested
the passengers to be there, letting them in the experience of your breathing. Use
be noisy if they are noisy and instead the rhythm of your breathing as an anchor
keeping your hands on the wheel and to keep your awareness in the here and
driving the bus in the direction you want now. You may like to practice mindfulness
to go. of the breath regularly. You can also
Practicing Mindfulness Mindfulness is practice mindfulness by being mindful in
the skill of keeping our awareness in the everyday activities such as washing the
here and now with acceptance of our own dishes or walking.
thoughts and feelings. Mindfulness
down Mindfulness of Emotions
a stream or clouds floating across To practice mindfulness of emotions allow
the sky. What do you notice? your awareness to settle onto the physical sensations of
the emotion. You may find
Values it helpful to imagine that the sensations
Values are what we want our lives to be are an object or a creature. Notice that
about. A value is a direction in which you you are bigger than the emotion and try,
want your life to go, like heading West. as best you can, to make room for it. Try
We never really finish living out our values to bring a sense of curiosity towards the
because there is always more to be done. emotion as if you are really interested in
Our values provide the basis for the goals what it is like to feel. This doesn’t mean
that we choose to act on day by day. you need to like the emotion or want it to
What do you want your life to be about? be there it just means making room for it and
allowing it to be there.
Taking Action What steps can you take to move closer to Thoughts are Just
Thoughts
your values? A value is a direction which Thoughts are just thoughts. We don’t
is never really finished like heading West. need to act on them, or react to them or
A goal is a step that you can complete like to prove them true or false. Having
getting to the next intersection. You may thoughts is like having a radio station on
find that you have some bigger goals that all the time. You could sit near the radio
will take time to achieve and that’s okay. all day listening intently or you could get
Ensure though that you also think of on with doing what you want to do and
plenty of small steps too. It is like stocking just let the radio be in the background.
the kitchen pantry. You want to plan for Try adding, “I’m having the thought
the days when you need ready-made that...” to your thoughts, or singing them,
snacks and easy meals! It may help to or saying them in a silly voice. You can
think, what is the smallest step I could also try watching your thoughts, perhaps
take? imagining that they are leaves floating
ACT in a Nutshell Accept your thoughts and feelings Choose a valued direction Take
Action towards your valued direction
Written by Koa Whittingham for the Stepping Stones Cerebral Palsy Project. Artwork conceptualised by Joseph Ciarrochi and David
Mercer & created by David Mercer