The Counseling Psychologist

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Quality of Life in Advanced Cancer: An Acceptance and

Commitment Therapy View
Julie E. Angiola and Anne M. Bowen
The Counseling Psychologist 2013 41: 313 originally published online 22
October 2012
DOI: 10.1177/0011000012461955

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461955
Counseling PsychologistAngiola and Bowen
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The Counseling Psychologist

Quality of Life in 41(2) 313-335

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DOI: 10.1177/0011000012461955
An Acceptance http://tcp.sagepub.com

and Commitment
Therapy View

Julie E. Angiola1 and Anne M. Bowen2

Abstract
Prognosis is poor and quantity of life is compromised for individuals with
advanced cancer. Quality of life is impacted, for some, by psychological dis-
tress. According to Acceptance and Commitment Therapy (ACT), psychologi-
cal distress is associated with emotional avoidance and lack of valued living.
ACT aims to increase psychological health via acceptance of one’s “minding,”
a focus on present-moment living, and a commitment to value-driven life. In
this article, we introduce the advanced cancer patient, the theory behind
ACT, and how ACT may be delivered. We present the hypothetical case of
J.B., a 56-year-old woman with recurrent Stage III ovarian cancer who reports
thoughts of hopelessness and worthlessness, and how ACT might be applied
to help J.B. experience a rich and meaningful life irrespective of her time
remaining.

Keywords
Acceptance and Commitment Therapy, cancer, psychological flexibility,
prevention/well-being

1
Department of Psychology, University of Wyoming, Laramie, WY, USA
2
Fay W. Whitney School of Nursing, University of Wyoming, Laramie, WY, USA

Corresponding Author:
Julie E. Angiola, Department of Psychology, University of Wyoming, 1000 E. University Avenue,
Laramie, WY 82071, USA
Email: [email protected]

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314 The Counseling Psychologist 41(2)

Advanced Cancer and Quality of Life

Individuals with advanced cancer, such as metastatic breast cancer and late
stage ovarian cancer, have poor prognoses, since seldom is their cancer cur-
able (American Cancer Society [ACS], 2012). Treatments are often offered
to reduce tumor size, alleviate symptoms, and prolong living, yet quantity
and quality of life remains uncertain.
Quality of life is further compromised by fatigue (Stone et al., 1999), pain
(Coyle, Adelhardt, Foley, & Portenoy, 1990; Vainio et al., 1996; Walsh,
Donnelly, & Rybicki, 2000), and psychological distress (Derogatis et al.,
1983; Grabsch et al., 2006; Grassi et al., 1996; Kissane et al., 2004; Kugaya
et al., 2000; Vehling et al., 2012; Wilson et al., 2007). It is estimated that as
many as 25% of advanced cancer patients meet diagnostic criteria for major
depressive disorder and as many as 35% meet the diagnostic criteria for an
adjustment disorder (Miovic & Block, 2007). As the literature indicates, not
every individual diagnosed with advanced cancer will experience clinically
significant psychological distress; so why do some individuals suffer psycho-
logically while others do not?
According to more recent “third wave cognitive behavioral therapies,” a
major risk factor for experiencing psychological distress is experiential
avoidance (Hayes et al., 2004; Kashdan, Barrios, Forsyth, & Steger, 2006;
Tull & Roemer, 2007). Experiential avoidance is the “phenomenon that
occurs when a person is unwilling to remain in contact with particular private
experiences (e.g., bodily sensations, emotions, thoughts, memories, behav-
ioral predispositions) and takes steps to alter the form or frequency of these
events and the contexts that occasion them” (Hayes, Wilson, Gifford, Follette,
& Strosahl, 1996, p. 1154). Contexts that trigger uncomfortable and distress-
ing private experiences are avoided, and attempts to control or distract
oneself from thoughts may occur. Individuals with cancer who avoid can-
cer-related cognitions and behaviors are at a greater risk for experiencing
psychological distress than those who do not use avoidance-based coping
strategies (Costanzo, Lutgendorf, Bradley, Rose, & Anderson, 2005;
Costanzo, Lutgendorf, Rothrock, & Anderson, 2006; Donovan-Kicken &
Caughlin, 2011; Dunkelschetter, Feinstein, Taylor, & Falke, 1992; Elani &
Allison, 2011; O’Brien & Moorey, 2010; Stanton et al., 2000). This phenom-
enon also appears in studies examining avoidant coping among HIV-infected
individuals, alcohol and pornography addicts, those with disordered eating,
and victims of childhood sexual abuse (Degenova, Patton, Jurich, &
Macdermid, 1994; Hayes et al., 1996; Masuda, Price, & Latzman, 2012;
Moser & Annis, 1996; Polusny & Follette, 1995; Wetterneck, Burgess, Short,

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Angiola and Bowen 315

Table 1. Summary Explanations of Common Acceptance and Commitment Therapy

(ACT) Concepts

Hayes, Strosahl,
ACT Concept Our Explanation & Wilson (2012)
“Minding” Our mind’s constant reasoning, p. 68
comparing, categorizing, arranging,
gauging, evaluating, planning, organizing,
sorting, etc., that occurs whether or
not we attempt to control/alter it.
Relational frames Relational responding pp. 44-48
Struggle/stuck When an individual is drawn into his or p. 64
her private, psychological experience,
tries to escape the distress, and thus
narrows the scope of his or her life.
Cognitive Fusion and Fusion—the inability to discriminate p. 244
Defusion thought from experience.
Defusion/Deliteralization—the
separation of thought from
experience. Seeing a thought for what
it is and not what it tells you it is.
Conceptualized Self The story or stories one formulates pp. 81-84
(self-as-content) about who he or she is and which
characteristics he or she possesses.
Your “identity.”
Ongoing self- Nonjudgmental noticing of continuously pp. 84-85
awareness (self-as- changing thoughts, feelings, behaviors,
process) sensations. Mindfully knowing oneself.
Observing Self / The aspect of self in which you are pp. 85-88
Perspective Taking looking from An “I, here, now” locus
(self-as-context) through which all is observed.

Smith, & Cervantes, 2012). The result of avoidance-based coping is not only
psychological distress, but often one’s life is “put on hold” in order to control
or escape the distress.
Findings from research with breast cancer patients further indicates that
individuals who employ acceptance-based coping of their emotions, as
opposed to avoidance-based coping, experience less psychological distress
(Carver et al., 1993; Politi, Enright, & Weihs, 2007). Emotional acceptance is
the nonjudgmental act of experiencing both positive and negative emotions.
In a longitudinal study examining coping strategies and quality of life among

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316 The Counseling Psychologist 41(2)

Table 2. Summary Explanations of Acceptance and Commitment Therapy (ACT)

Exercises and Metaphors

ACT Exercise/
Metaphor Our Explanation Original Source
Gift Watch Client is asked, “What would you hope to Hayes, Strosahl,
exercise see engraved on a watch received as a gift? & Wilson
What would you like others to say about (2012,
you and what you stood for? What would pp. 306-307)
you like your life to stand for?”
Chinese With actual Chinese handcuffs in session: Hayes, Strosahl,
Handcuffs Attempting to pull both index fingers from & Wilson
metaphor the tube tightens the grip of the tube. (2003, p. 105)
Counterintuitively, pushing in gives your
fingers some room to move. Perhaps in
order to live life, we make some room in
your life. Maybe we push in . . .
2-minute Eyes closed, at the beginning of session: we Hayes, Strosahl,
mindfulness take several deep breaths, notice the noises & Wilson
exercise in the room, the feeling of our bodies in (2012, p. 207)
the chairs, mentally scanning our bodies
for sensations and minds for thoughts and
emotions.
Milk, Milk, What comes to mind when you hear the Hayes, Strosahl,
Milk exercise word milk? What else? What shows up? & Wilson
Let’s say milk out loud, together. (Counselor (2012,
and client say the word milk, quickly, for 1 pp. 248-250)
minute.) What did you notice? What did
you hear? (Clients often report the word
becomes just a sound, nonsensical, and
loses meaning.) The word milk became just
a word and didn’t feel as if it were actually
here, being experienced, like it first did.
Joe the Bum Imagine having a housewarming party and Hayes, Strosahl,
metaphor everyone in the neighborhood is invited. & Wilson
You post signs inviting everyone to stop by. (2012. p. 279)
Unfortunately, a stinky, dirty neighbor shows
up and you’re embarrassed and annoyed.
You spend a lot of time shooing him out and
guarding the door from his reentry (and he
tenaciously reenters again and again) and
that’s a ton of work! All the while you’re not
enjoying your own party. The party is going
on all around you but without you. The
question is, What would you do?

(continued)

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Angiola and Bowen 317

Table 2. (continued)

ACT Exercise/
Metaphor Our Explanation Original Source
Soldiers in Imagine that there are little soldiers marching Hayes, Strosahl,
the Parade out from your left ear, down in front of you & Wilson
exercise in a parade.You are watching them come (2012,
and go from a reviewing stand in the middle. pp. 255-258)
Imagine that each soldier carriers a blank
sign. Notice what thoughts or images come
up for you and place each one on a passing
soldier’s sign. The goal is to fill the signs and
watch the parade go by. Every time you feel
yourself pulled into something else or the
parade stops, notice that and go back to
watching the parade.
Eye Contact Client and counselor sit closely across Hayes, Strosahl,
exercise from one another, even knee-to-knee, & Wilson
for 3 minutes while maintaining direct (2003,
eye contact silently. The client is asked to pp. 244-245)
be mindful of what comes up for them
(thoughts, feelings, sensations) and to
notice how he or she comes and goes from
being fully present. This is an exercise in
being willing to experience discomfort and
distress but still commit to a valued action.
Observer Eyes closed (preferably): beginning with deep Hayes, Strosahl,
exercise breaths and mindfulness. The counselor & Wilson
then directs client to focus attention on the (2012,
observing self (the person who has been pp. 233-237
with you your whole life, noticing thoughts,
emotions, and sensations, always aware and
always present). The client is then guided
to memories from a recent time, teenage
years, and around 6 or 7 years old. The
counselor then guides the client to notice
his or her body sensations, roles, emotions,
and thoughts and while all of these changes
constantly come and go, the client has
always been the client. In essence, the
client is not just roles, memories, thoughts,
feelings, and a body—these are the content,
while the client is the context.

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318 The Counseling Psychologist 41(2)

70 Stage I and II breast cancer patients, emotional acceptance at the time of

diagnosis predicted decreased distress and increased positive mood 1 year
later (Stanton, Danoff-Burg, & Huggins, 2002).
While many individuals living with an illness such as advanced cancer
may employ acceptance coping strategies and thus invest in a renewed sense
of self (Ando, Morita, Lee, & Okamoto, 2008; Helgeson, Reynolds, &
Tomich, 2006; Taylor, 2000), others may find emotional acceptance difficult
to muster. At diagnosis, in treatment, and during end-of-life care, living with
cancer may spark an existential crisis, calling into question one’s mortality,
purpose or identity, and religiosity/spirituality (Alcorn et al., 2010; Gall &
Cornblat, 2002; Hui et al., 2011). A recent multicenter study found that 88%
of advanced cancer patients considered religion and spirituality (R/S) to be
important facets to coping with their illness (Balboni et al., 2007), including
the utility of spirituality in aiding with making meaning of their illness
(Carlson & Halifax, 2011). Thus, R/S coping, the use of religion or spiritual-
based cognitive and behavioral techniques in the face of distressing events
(Tix & Frazier, 1998), is one of the most commonly utilized coping strategies
employed by individuals with cancer (Jenkins & Pargament, 1995). R/S cop-
ing strategies are associated with increased quality of life (Nelson, Rosenfeld,
Breitbart, & Galietta, 2002) and a heightened sense of personal purpose and
understanding (Daaleman & VandeCreek, 2000).
Yet attending to a cancer patient’s spiritual needs to foster a sense of pur-
pose, in the context of psychotherapy, is an emerging practice. While Dignity
Therapy (Chochinov, 2002; Chochinov et al., 2005), Meaning Making
Intervention (MMi; Henry et al., 2010; Lee, Cohen, Edgar, Laizner, & Gagnon,
2006), and other interventions (for review, see LeMay & Wilson, 2008) appear
promising, there remain limited data on their efficacy. Furthermore, the above-
mentioned interventions do not directly address experiential avoidance, a pro-
cess by which psychological health is also compromised. In summation,
advanced cancer patients may be best aided by a psychotherapy that promotes
acceptance in the face of distressing internal, private events (i.e., cognitions,
memories, and sensations), while also helping patients lead valued, meaning-
ful lives in the unpredictable and possibly short amount of time remaining.
In a recent survey study (Ciarrochi, Fisher, & Lane, 2011) of values and well-
being in individuals with cancer, valued living was negatively correlated with
emotional avoidance and thus cancer-related distress. Furthermore, valued liv-
ing was positively correlated with psychological well-being. The results from
this study suggest two things: First, values and avoidance are two distinct pro-
cesses, as previously cited in the literature (Wilson & Murrell, 2004). Second, a
value-based psychotherapy that concurrently targets experiential avoidance is
appropriate and would be of untold value for advanced cancer patients.

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Angiola and Bowen 319

Acceptance and Commitment Therapy (ACT)

ACT (pronounced as a single word) is such an intervention (Hayes, Strosahl,
& Wilson, 2012). ACT has been applied to numerous mental and behavioral
health concerns, including anxiety and depression, chronic pain, alcohol-
related self-stigma, nicotine dependence/smoking cessation, math anxiety,
work stress, opiate dependence, weight control, promotion of physical activity,
trichotillomania, psychosis, epilepsy, tinnitus sequalae, borderline personality
disorder (Butryn, Forman, Hoffman, Shaw, & Juarascio, 2011; Luoma,
Kohlenberg, Hayes, & Fletcher, 2012; Powers, Vording, & Emmelkamp, 2009;
Westin et al., 2011), and the list is ever growing. There are 62 Randomized
Controlled Trials (RCTs) of ACT that have either been published or are cur-
rently in press (for a complete list, see Association for Contextual Behavioral
Science, 2012). Results from RCTs as well as correlational, component, pro-
cesses of change, and outcome comparison studies generally support the use of
ACT for the above-mentioned clinical phenomena (Hayes, Luoma, Bond,
Masuda, & Lillis, 2006; Powers et al., 2009; Pull, 2009). Officially, ACT is
listed on the National Registry of Evidence-Based Programs and Practices by
the United States Substance Abuse and Mental Health Services Administration
(SAMHSA, 2012) as well as on the American Psychological Association’s
(APA) Division 12 Empirically Supported Treatment page, showing moderate
support for depression, obsessive compulsive disorder, and mixed anxiety
disorders and strong support for chronic pain and psychosis.
The examination of the suitability and efficacy of ACT for individuals with
cancer is increasing. In a theoretical-based article (Karekla & Constantinou,
2010), ACT is posited to be a psychotherapeutic intervention particularly adept
at addressing R/S by way of mindfulness, acceptance, and valued living. The
authors illustrate the application of ACT to a hypothetical breast cancer patient
with particular sensitivity to the patient’s Greek Orthodox faith. It has been pre-
viously noted elsewhere that some of ACT’s methods appear to be Buddhist in
nature (Hayes, 2002; Shenk, Masuda, Bunting, & Hayes, 2006), making ACT a
particularly fitting intervention for patients who consider spirituality part of their
self-identity. Although there are few empirical studies of ACT for individuals
with cancer, as described below, their preliminary finds are promising.
Paez, Luciano, and Gutierrez (2007) conducted a small RCT comparing
eight sessions, three individual and five group sessions, of ACT (n = 6) and
Cognitive Behavioral Therapy (CBT; n = 6) with breast cancer patients.
Follow-up data at 12 months posttreatment showed that participants in the
ACT condition had clinically significant lower depression and anxiety and
higher quality of life than participants in the CBT condition (d = 1.78).

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320 The Counseling Psychologist 41(2)

Research presented at the third annual American Psychosocial Oncology

Society conference included a study of fear of relapse among breast cancer
patients (Montesinos, Luciano, Paez, & Remedios, 2006). A one-session
ACT intervention was applied to eight Stage I and II breast cancer patients.
Results showed that ACT was successful in decreasing intensity and severity
of relapse-related fears in seven of the eight participants. ACT was also
shown to produce clinically significant reductions in emotional distress.
A recent study (Feros, Lane, Ciarrochi, & Blackledge, 2011) aimed to
examine ACT for various types of cancer. Participants (N = 45) engaged in
nine weekly individual sessions of ACT. Results indicated that during the
nine sessions, at postintervention, and 3-month follow-up, participants
reported significant improvements in quality of life, psychological distress,
negative mood, and overall psychological flexibility.
Rost, Wilson, Buchanan, Hildebrandt, & Mutch (2012), in the only study
to date using ACT for advanced cancer patients, specifically ovarian cancer,
conducted an RCT comparing ACT to Treatment as Usual (TAU). Thirty-one
women with Stages III and IV ovarian cancer were randomly assigned to 12
sessions of either an ACT (n = 25) or TAU (n = 22) condition. Participants in
the ACT condition reported statistically significant greater and more rapid
decreases in psychological distress and increases in quality of life than the
TAU condition. The researchers posit that although during the course of the
study the physical health of participants was declining (12 participants passed
away during the study), the improvement on quality of life is the result of
increased acceptance and valued living. Interestingly, and in alignment with
the tenets of ACT, “mental disengagement” (i.e., experiential avoidance) and
“active planning” (i.e., value-driven committing) proved to be outcome
mediators on both quality of life and psychological distress.

The Application of ACT for

Individuals With Advanced Cancer
What Exactly Is ACT?
Simply stated, ACT helps individuals learn ways to detach and let go of distress-
ing thoughts and feelings, be more present-focused and mindful, clarify what
they value in life, and commit to living value-laden and enriched lives. Thus,
ACT, conceptualized as “contextual cognitive behavioral therapy” (Hayes,
Villatte, Levin, & Hildebrandt, 2011), aims to help individuals become psycho-
logically flexible (Hayes et al., 2012; Spiegler & Guevremont, 2010).
Psychological flexibility is defined as “the ability to contact the present moment

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Angiola and Bowen 321

more fully as a conscious human being, and to change or persist in behavior

when doing so serves valued ends” (Hayes et al., 2006, p. 8). When thoughts,
emotions, sensations, and memories are not changed, escaped, blindly followed,
or avoided, their control on overt behavior is considerably reduced. By allowing
thoughts, emotions, sensations, and memories to occur without the intent to
“cure,” individuals are able to do what they value instead of being drawn into
their immediate psychological struggle (Kohlenberg, Hayes, & Tsai, 1993). The
six core processes, as represented in the ACT Hexaflex model—acceptance,
cognitive defusion, being present, a sense of self known as “self as context,”
values, and committed action—are posited to be the skills needed in order to
achieve psychological flexibility (Hayes et al., 2012).

Why Do People Struggle?

In order to understand why some individuals get drawn into their private,
psychological struggle or get stuck, we must first briefly look at the role of
language in cognitions. ACT developed in conjunction with its own theory
on how language influences cognition and thus behavior. Relational Frame
Theory (RFT; Hayes & Wilson, 1993) posits that humans learn to respond in
relation to various stimuli (i.e., seeing a dog, hearing the word dog, and
associating the sound “dog” with dogs), eventually combining arbitrary com-
binations as if they are somehow related (e.g., dog → dog bite → pain →
crying → parent’s divorce, ergo dog ↔ parent’s divorce). Thus, a network of
relational frames is inevitably created (Table 1).
For example, if an individual with advanced cancer is afraid of the needles used
for his or her chemotherapy treatment, he or she becomes anxious. If that same
individual with advanced cancer simply thinks of the chemotherapy needle, he or
she will also become anxious. In order to avoid thinking about needles, the indi-
vidual tries to distract him- or herself with thoughts of being at the ocean. On one
level, this distraction may work. RFT posits, however, that in order for the indi-
vidual to think of the ocean, he or she must also think of needles (i.e., the relational
frame is set). The individual has now created an additional relation in which being
at the ocean and fear of needles has been networked. It is now likely that the next
time the individual thinks of being at the ocean, he or she will activate thoughts of
chemotherapy treatment needles and thus may also feel anxious.
The phenomenon of relational framing also occurs with emotions and
memories. For example, if an individual with advanced cancer recounts how
his or her doctor delivered the prognosis, he or she may become anxious and
depressed. Most likely the advanced cancer patient was able to re-experience
the scenario, using his or her senses to see the treatment room, hear the sounds

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322 The Counseling Psychologist 41(2)

of the office, and feel his or her stomach drop when hearing the prognosis.
What has happened is that the recounting of this moment now functions in
much the same way as the original, real moment. Thus, the individual with
advanced cancer may react in the same way as when he or she was first given
the prognosis, as a result of the fusing of these events (Hayes, Strosahl, &
Wilson, 1999). Yet this alone does not lead one to become stuck since rela-
tional framing is a distinct facet of being human (Hayes et al., 2006; Hayes
et al., 2004). Furthermore, research indicates that individuals with cancer,
who undoubtedly have vast relational frames regarding their illness, are often
able to lead meaningful lives (Thompson & Pitts, 1993).
ACT theory suggests that where getting stuck occurs is in one’s relationship
to internal, private events (Table 1). Thoughts, feelings, and memories—inter-
nal private events—are not in themselves “bad,” maladaptive, or pathological.
At some point, however, the stuck individual has fused these internal events
with his or her identity (e.g., “I am depressed” instead of “I am feeling
depressed”). In an attempt to alter these internal, private events, humans engage
in “minding,” (Table 1). “Minding” entails our constant reasoning, comparing,
categorizing, evaluating, planning, organizing, sorting, and so forth and occurs
whether or not we wish it to or attempt to alter or control it (Hayes et al., 2012).
“Minding” for the external versus internal world may look much like this: “My
medical bill is due today but I can’t afford it until later. I will pay the bill next
week.” Compare that to “I’m hopeless and sad and I can’t handle it so I won’t
think about my sadness right now.” This “minding” is not likely to work;
humans cannot simply shut off or avoid certain internal events, such as unpleas-
ant thoughts. Proof of the ineffectiveness of controlling “minding” has been
presented in research that shows how efforts to suppress thoughts are ineffec-
tive and conversely increase the quantity and valence of said suppressed
thoughts following supposed extinction (see “White Bear” suppression exer-
cise; Wegner, Schneider, Carter, & White, 1987; Wegner & Zanakos, 1994).
Additionally, experiential avoidance tactics, while in the short term may pro-
duce a positive affect (i.e., relief from distress), will result in the avoided event
resurfacing more powerfully (Wegner & Zanakos, 1994).

How Does ACT Work?

Whereas CBT places emphasis on changing the content of “minding” via
cognitive restructuring (Beck, 2011), ACT places emphasis on changing the
context of “minding.” The aim of ACT is to change the relationship indi-
viduals have with their internal events while helping them to clarify their
values and commit to vale-congruent actions in order to expand and enrich

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Angiola and Bowen 323

their effective behaviors. ACT helps one to distinguish thoughts from his or
her person (e.g., “I am ill” versus “I have an illness”), since the inability to
distinguish the thought from the person is believed to have deleterious con-
sequences (Hayes et al., 2012). Moreover, the discovery of self as context
emerges—one becomes aware of one’s own stream of experiences (including
thoughts, feelings, and memories) over time without being drawn into par-
ticular incidents or attached to specific future incidents (e.g., “I must only fill
my life with good memories”). Thus, the transcendence of self occurs where
one views the self as context, or perspective, and not as content. The self
becomes a consistent perspective (e.g., the ACT Bicycle metaphor: “You are
always falling over and yet you move forward”) with which to view and
accept all experiences.
According to ACT, accepting thoughts as thoughts, emotions as emotions,
and memories as memories—nothing more and nothing less—results in the
dismantling of cognitive fusion in a process called cognitive defusion (Table 1).
Accepting, and not struggling with, one’s internal events allows his or her
behavioral repertoire to expand; when one is not engaged in “fighting” with
his or her distress, other ways in which time can be spent become available.
When this occurs, individuals can commit to leading valued, meaningful
lives. Psychological flexibility has been thus increased.
In the last section of this article, we present a prototypic case example illus-
trating how ACT might be applied to an individual with advanced cancer.

The Case of J.B.

J.B. is a 56-year-old European American female. J.B. resides with her hus-
band, a home contractor; they have been married for 34 years. J.B. and her
husband have two daughters, ages 28 and 30, who live in neighboring towns.
In the past, J.B. would see both of her daughters at least once a week. J.B. is
currently on medical leave from her job as an administrative assistant for the
local school district.
J.B. was diagnosed with Stage IIIC1 epithelial ovarian cancer2 at age 53,
underwent surgery and five cycles of chemotherapy, and was in complete
remission. Twelve months later, J.B.’s CA-1253 levels had increased and a
recurrence of the ovarian carcinoma was detected by CT/PET scan. J.B.
underwent a second successful surgery and three more rounds of chemother-
apy. She has been in remission for 6 months.
On a recent visit to her gynecologic oncologist, results of J.B.’s blood test,
once again, revealed increased CA-125 levels. Results from a PET/CT scan4
confirmed recurrence of cancer, and J.B.’s gynecologic oncologist suggested

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324 The Counseling Psychologist 41(2)

additional chemotherapy. J.B. stated that she felt “too hopeless to make these
decisions right now” and told her doctor that she would “think on it.” After
not hearing from J.B. for 3 weeks, the gynecologic oncologist called J.B. to
discuss treatment planning. J.B. stated that she was finding it difficult to get
out of bed and didn’t have the energy to speak with her physician. J.B. was
referred by her gynecologic oncologist for mental health services and saw the
ACT counselor 2 months after she was told the cancer had come back.

The Functional Analysis: Listening and Seeing as an ACT Clinician

During intake, the ACT counselor aims to answer two questions. First, what
type of life does J.B. want to live in the possibly short amount of time
remaining? Second, what psychological and environmental barriers are pro-
hibiting her from living that life? The ACT counselor began to answer these
questions by first listening for verbal accounts of struggle and looking for
nonverbal behaviors that signal struggle.
J.B. often looked out the window and down at the floor during the intake
session. Her posture suggested fatigue as she was slumped down in her chair
with her head resting on the chair back. When asked a question, J.B. would
first pause and then begin answering slowly, with her voice often fading out
midsentence. Each word and sentence appeared to take a great deal of energy.
J.B. repeated several times that she was “hopeless” and “worthless” and that
she “didn’t know.” She stated that she was spending almost all day, every day
in bed alternating between crying, “feeling numb and staring at the ceiling,”
and “nonstop worrying.” J.B. worried about many things, including whether
or not she should even undergo chemotherapy, how much time she had
remaining, if God was punishing her for something and why her begging for
forgiveness wasn’t working, and losing her husband, daughters, and friends.
J.B. had stopped returning calls from friends and work colleagues and had
not seen her two daughters in weeks. She reported that she was “ashamed” of
how she was “acting” and that she should just “suck it up and move on” like
“good Christians do.” J.B. said that she also felt guilt over not seeing her
gynecologic oncologist, as recommended. J.B. stated that although she
wanted to spend time with her husband, she “didn’t want to be a burden”;
therefore, she stayed in the guest bedroom of their house. Lastly, J.B. had also
given up her hobbies of photography and book club, telling the counselor
“what’s the point?” Although J.B. felt that she was missing out on life, she
stated, “I don’t understand how I can live while I die.”
In addition to the intake interview, J.B. was given the Acceptance and
Action Questionnaire (AAQ; see Hayes et al., 2004) to assess her level of

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Angiola and Bowen 325

experiential avoidance and the Valued Living Questionnaire (VLQ; see

Wilson, Sandoz, Kitchens, & Roberts, 2010) to assess domains of valued liv-
ing and the extent to which she behaved in accordance with those values every
day. J.B.’s score on the AAQ indicated that lack of defusion, acceptance, and
living in the now were the biggest problems, while her values were a relative
strength. Furthermore, scores from her VLQ indicated that family relations,
marriage relations, social relations, spirituality, physical well-being, and rec-
reation were her most important values. However, scores on how consistent
her actions were in these domains were low, indicating that while these are all
important values, she was not actively living in accordance with these values.
J.B.’s scores on the AAQ and VLQ provide corroborating evidence regarding
her high experiential avoidance and lack of valued living.
In the case of J.B., the ACT counselor believed that J.B. had “bought into”
the idea and self-identified as hopeless, punishable, and a bad mother, wife,
friend, and Christian, as a result of cognitive fusion. She displayed verbal and
nonverbal evidence of her lack of contact in the present moment, including
her poor eye contact in session, continuous referral to the past, ruminative
thinking of what she had done wrong or how she had angered God, and
recounting tales of things she had done with family and friends when she was
“able” in the past. When asked during intake what she was experiencing
“now” in the room with the counselor, J.B. looked at the floor, shrugged, and
responded, “I don’t know.” J.B. experientially avoided her internal events
(e.g., “numbed out”) and had displayed overt external avoidance (e.g., stay-
ing in bed all day, not attending medical appointments, and disengaging from
loved ones) all in the hopes of feeling better. She stated that she “didn’t want
to be sick and have these terrible thoughts.” The focus of ACT with J.B. was
on accepting her thoughts, emotions, and memories and making room for
them to “just be” while at the same time helping her to recommit to a valued,
meaningful life.

Session Progression
Given the uncertainty of J.B.’s future, sessions commenced with values and
commitment work. It should be noted that although ACT does include six core
processes, there is no prescribed order for administering ACT. Nor should clini-
cians feel that they must address each of the six processes with every client.
Quantity and order of targeted processes is determined by the functional analy-
sis and is thus made on a case-by-case basis (Hayes et al., 2012).
Using J.B.’s self-reporting that she highly valued family, marriage, social
relations, spirituality, physical well-being, and recreation, the counselor

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326 The Counseling Psychologist 41(2)

asked J.B. how these areas might be improved if she could stop fighting her
internal events. Since ACT posits that our “minding” results in unsatisfactory
action guidance especially in the context of control, literality, and reason giv-
ing (e.g., “if only I could stop being so sad, I could spend some quality time
with my husband”), the counselor was hoping to illustrate just how much J.B.
had given up in her control of her sadness, hopelessness, and fear. These ses-
sions focused on J.B. evaluating what she wanted her life to stand for, and
this was done with the aid of the Gift Watch Exercise (Table 2; e.g., “What
would you want inscribed on the back of your gift watch? What would you
want others to say about who you are and what your life stands for?”). The
counselor then helped J.B. to understand the difference between a value (i.e.,
a continuous commitment to a specific domain) and a valued action (i.e.,
behavioral steps). J.B. and the counselor next generated actions (i.e., mini-
goals linked to larger goals) that were consistent with J.B.’s values. For
example, J.B. stated that she highly valued spirituality and she had made one
of her values “being a good Christian.” She and the counselor were able to
identify that one of her goals was to help “those who are suffering more than
me,” achieved, in part, by visiting homebound individuals. J.B. and the coun-
selor further broke “visiting homebound individuals” into smaller goals,
including calling her church to be placed on the roster and scheduling her first
home visit. Breaking down larger goals into smaller actions, in the service of
larger goals, was done for each of her self-reported values.
Values clarification work led into a discussion of the ramifications of fighting
a psychological battle. The counselor asked J.B. about the methods she used to
control or escape her distress, and J.B. provided an exhaustive list, including
“numbing out,” crying, distracting, trying to only think positive thoughts, and
chastising and threatening herself when she had a distressing internal event (e.g.,
“Don’t you dare think that!”). J.B. was commended for having worked so hard
and tried so many different methods. Letting go of the struggle for cognitive
control was presented to J.B. via the Chinese Handcuffs metaphor (Table 2).
Letting go was done by examining the workability of previous attempts of con-
trolling her internal events (i.e., J.B. tried to pull her finger from the woven tube
and it tightened further, being a metaphor for her attempts to avoid certain feel-
ings) and introducing the idea that by pushing into the tube and into her distress,
J.B. may find she has room to move her finger, room to live.
In order to truly live, one must first be present. The counselor and J.B. then
progressed into working on bringing J.B.’s attention into the present moment.
For example, the counselor helped J.B. attend to the “now” by asking J.B. to
describe what was present for her during responses of “I don’t know.” The
counselor asked J.B. to scan her body, noting sensations in response to “I
don’t know” and listening to her breath and her voice, all in an effort to help

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Angiola and Bowen 327

J.B. make contact with the “now.” Subsequent sessions were begun with a
2-minute mindfulness exercise (Table 2).
Mastering being mindful led into helping J.B. view herself in three forms:
the conceptualized self, ongoing self-awareness, and the observing self
(Table 1). J.B.’s conceptualized self, how she thought of herself, was stated
as, “I am a woman dying of ovarian cancer.” J.B.’s ongoing self-awareness,
her ability to be aware of and use continual behavioral states in order adjust
to the daily, changing circumstances of life, was now more developed thanks
to her previous present-moment work. Lastly, J.B.’s observing self, the “per-
son behind your eyes” (Hayes, Strosahl, & Wilson, 1999, p. 186), was some-
one who had always been with her, experienced everything, and could
contact those moments freely.
The counselor helped teach J.B. that she is not defined by her private
experiences, or “minding;” rather she is an individual who contains private
experiences, and these experiences do not need to be evaluated or changed,
and should be experienced by the peaceful, nonjudgmental, nonevaluative
observing self. J.B. was able to successfully complete the eyes-closed
Observer Exercise (Table 2) in which she was asked to notice how her emo-
tions are constantly changing while she remains the constant, observing per-
spective. J.B. was able to defuse her sense of self from her experience of
emotions (e.g., “I have the emotion of sadness, but I am not sadness”).
Further defusion exercises included the Milk, Milk, Milk exercise (Table 2),
in which what milk represents and brings to mind is dissociated from the word.
J.B. then did this repetition exercise with personally high-valence words such
as worthless, useless, and sick. Deliteralization strategies were also used to
disrupt J.B.’s problematic language routines, as in the case of sadness (reason
giving) preventing her from acting—“I wanted to attend the book club meet-
ing last week, but I was feeling too blue” versus “I wanted to attend the book
club meeting last week, and I was feeling too blue”—thus enabling an
expanded behavioral repertoire. Changing but to and implies an acceptance
of the experience regardless of the literal contradiction and now weakens the
association between feeling blue and eliminating social engagements. This
exercise paved the way for the last focus of treatment—acceptance.
J.B. was taught numerous metaphors and exercises, including the Joe the
Bum metaphor and the Soldiers in the Parade mindfulness exercise (Table 2). In
the last one, J.B. was asked to notice internal events and then “place” any
thought (e.g., “I am going to leave my husband a widower”), feeling (e.g., guilt
over not spending time with husband), belief (e.g., “A good mother would
choose to undergo more chemotherapy”), or body sensation (e.g., emptiness or
pain) onto imagined placards carried by soldiers marching in a parade. This
mindfulness exercise allowed J.B. to contact these experiences in the present

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328 The Counseling Psychologist 41(2)

moment without judgment and with the intention of “making space” for them—
in other words, with acceptance. Acceptance of distress was also taught via the
Eye Contact exercise (Table 2), in which J.B. and the counselor sat across from
one another, knee-to-knee, for 3 minutes while maintaining direct eye contact
silently. This exercise asked J.B. to stay present and engaged in the “now,”
despite the urge to look away, nervously giggle, or be consumed by thoughts
(e.g., “I wonder if I look as tired as I feel right now”). The goal of this exercise
was to show J.B. how she could accept distress when acting on a value. Treatment
came full circle and ended with a discussion of how, even with her “minding,”
J.B. had the acceptance skills to reinvest in a life that she deemed worth living.

Conclusion
The above-mentioned case of J.B. illustrated how ACT can be used with
advanced cancer patients. ACT helped J.B. accept her thoughts, feelings, and
memories and successfully change her sense of self, from one fused with
content to one free to experience in a more objective and accepting way. J.B.
was better able to “tap into” and live in the present moment while also doing
what mattered to her. In essence, J.B. was able to accept and commit.
Similar to the hypothetical case of J.B., ACT provides a psychotherapeuti-
cally comprehensive way to help advanced cancer patients live rich, meaningful
lives regardless of quantity of time remaining. Preliminary data suggest that
ACT is helpful for a variety of cancer-related concerns and may be an especially
suitable intervention for those with advanced cancer. The intention of this article
was to briefly and as simply as possible describe the theory of ACT and how it
could be applied to an advanced cancer patient. This article is not an exhaustive
guide on how to “do” ACT. Furthermore, it should be noted that ACT is not a set
protocol or manual. As there is no singular prescribed way of “doing” ACT,
counselors who conceptualize from an ACT perspective are encouraged to use
the exercises provided in the ACT seminal book (Hayes et al., 2012) as well as
create exercises that are personally relevant and useful. The Association for
Contextual Behavioral Science (ACBS), which is considered ACT’s clinical and
research home, has an ever-growing list of exercises and metaphors, developed
by and shared freely among those in the ACT community. As a result, ACT in
practice aims to create in its clinicians what it does in its clients—flexibility.
Of course, no one form of therapy should be considered a panacea.
Nonetheless, the research support for ACT is growing. Counselors looking
for a treatment approach that addresses cognitions and behaviors with a con-
current eye to spiritual and transcendent issues would be well advised to learn
more about ACT.

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Angiola and Bowen 329

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The authors received no financial support for the research, authorship, and/or publica-
tion of this article.

Notes
1. The cancer cells have metastasized to tissues outside the pelvis or regional lymph
nodes. This is the final stage before Stage IV, incurable epithelial ovarian cancer
(www.cancer.gov).
2. This is cancer of the cells on the surface of the ovary (www.cancer.gov).
3. This is a substance that may be found in high levels of the blood in patients with
ovarian cancer. CA-125 levels are often used to assess treatment efficacy and
cancer recurrence (www.cancer.gov).
4. This combines PET and CT into one set of images. The PET scan utilizes radioac-
tive glucose solution and functional imaging of tissue function/cell activity. The
CT scan utilizes contrast agents and cross-sectional structural images, or slices
(www.radiologyinfo.org).

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Bios
Julie E. Angiola, MS is a clinical psychology doctoral student at the University of
Wyoming and is currently a predoctoral intern at Geisinger Medical Center. Her pri-
mary research focuses on various health problems, including cancer and obesity, and
the application of Acceptance and Commitment Therapy to the psychological
sequelae of these issues. Additional research and clinical foci include behavioral
medicine, primary care, and rural health.

Anne M. Bowen, PhD, is a professor in the Fay W. Whitney School of Nursing and
Director of the Nightingale Center for Nursing Scholarship at the University of
Wyoming. Dr. Bowen is a licensed clinical psychologist with interests in health pro-
motion and interventions for people with chronic illnesses. Her research focuses on
reducing risks for acquiring and transmitting the HIV virus. Dr. Bowen is especially
interested in developing interventions for rural people. She recently completed an
Internet intervention for rural MSM with exciting results and is currently developing
an Internet intervention to reduce depression among rural men who have sex with
men. The intervention will be innovative in that the approach utilizes the techniques
of Acceptance and Commitment Therapy (ACT) and mindfulness to help men live the
life they want to live.