Welcome back to the Healing Pain Podcast with Jill Stoddard, PhD

We have clinical psychologist, Dr. Jill Stoddard. She’s going to be talking about the topic of Experiential Practice in Acceptance and Commitment Therapy for Chronic Pain. Jill is the Founder and Director of the Center for Stress and Anxiety Management, an outpatient psychotherapy clinic specializing in Acceptance and Commitment Therapy as well as Cognitive Behavioral Therapy for anxiety. She received her PhD in Clinical Psychology from Boston University and completed her postdoctoral fellowship at the University of California, San Diego School of Medicine. She’s an award-winning teacher as well as an ACT trainer who has co-authored articles on ACT, CBT, anxiety, trauma and pain. She’s also co-authored two books, the first being The Big Book of ACT Metaphors as well as her second book which is called Be Mighty: A Woman’s Guide to Liberation from Anxiety, Worry, and Stress Using Mindfulness and Acceptance, which will be published in January of 2020.

The reason why I want to have Jill come onto the show and especially talk about metaphor is that ACT is one technique that you can use to unhook from unpleasant thoughts. Oftentimes, it’s this unhooking from the unpleasant thoughts or other unpleasant sensation in your body that leads to the alleviation of the human suffering that many of us experience with chronic pain. You will learn about the foundational principles of ACT, why patients may prefer ACT over traditional CBT, how language causes suffering, the importance of Experiential Practice in ACT using metaphor, and the importance of values as part of the recovery process.

If you’re new to how ACT uses metaphors, I’ve included three metaphors that you can use with your clients or with yourself to help ease and live your life beyond pain. To download them, all you have to do is text the word 139DOWNLOAD to the number 44222 or if you’re on your computer, all you have to do is type in the URL www.IntegrativePainScienceInstitute.com/139download. Take a moment to download those three ACT metaphors. They’re going to help you as you read this blog post. Let’s begin with Dr. Jill Stoddard.

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Experiential Practice In ACT For Pain with Jill Stoddard, PhD

How To Use Metaphor In ACT

Welcome to the show, Jill. It’s great to have you here.

Thanks for having me. I’m excited to be here.

I’m excited to talk about metaphors. I know they’re used in psychotherapy, especially in ACT. They are also used by a lot of physical therapists trying to explain pain to people in a way that is easy to understand. We’re going to talk about metaphors. You wrote a book called The Big Book of ACT Metaphors, which came out a few years ago. It’s a practitioner guide. I use it and refer to it all the time. I recommend that people check it out. Interestingly enough, I first came across your work by finding a paper on PubMed. Often, many of us clinicians are in PubMed looking for things. You were involved in a paper in 2011 in The Journal of Pain. It’s called A Randomized Controlled Trial of Acceptance and Commitment Therapy and Cognitive Behavioral Therapy for Chronic Pain.

There are a couple of things in there that were interesting to me as a clinician. The first being that one, it looked at too important Cognitive Behavioral Therapy with regard to pain. It’s also one of the first studies that I found with regard to ACT where it was pulled out of a multidisciplinary approach. Many of the ACT for pain papers are set in multidisciplinary clinics, which is wonderful in the way that chronic pain should be treated. Here in the US, we don’t have many multidisciplinary clinics. Practitioners like you and I are in private practice where we’re using one or maybe two interventions. Can you talk to me a little bit about the importance of that paper?

This was a comparison of two group treatments. It was done at the VA in our primary care clinic. I believe the clients had to have chronic pain for a minimum of six months. Although to my recollection, most of them had chronic pain for quite a lot longer than that. They were randomized to either receive group CBT or group ACT. It was eight weekly sessions and they were 90 minutes or two hours, and that was it. It was a relatively brief intervention. They did have to stay stable on their medications and things like that so that we knew any of the changes we were seeing were due to the therapy and not because they were making big changes in other places.

What we found is that everybody got better. CBT and ACT performed equally well and that was a big deal. This was a few years ago and ACT has exploded at that time. We passed the 300 RCT mark. At that time there were not many studies. For ACT to perform equally to CBT being the gold standard treatment for many different things was a big deal. The other thing that I found super interesting that happened in this study is the attrition rates were the same. People weren’t dropping out differently from different groups. When we asked the patients to rate their satisfaction with the treatment at the end, there was a quite large significant difference in favor of ACT. Everybody got better but the people in the ACT group preferred ACT to CBT.

It’s incredibly important because when we’re looking at patient compliance for different types of treatment approaches. If someone is more satisfied with one approach, especially with chronic pain, it can be difficult. People need therapy sometimes for weeks or months. That ACT may be preferred in the clinical setting over traditional CBT. Even through these wonderful years of research about CBT being effective, satisfaction is still important for patients.

The other reason it’s important is that maybe for clinicians who are newer to ACT or even to patients, when we’re trying to explain ACT even just this word acceptance. I know when I first started using ACT for chronic pain, I was braced for a lot of pushback like, “What do you mean I have to accept my pain?” If you have a solid understanding of what it means which isn’t liking, wanting, giving in, giving up or resignation, but simply allowing something present anyway, changing your relationship to it, and living the best life you can even when you’ve been dealt this hand. We’re all anticipating that people would have a negative reaction to this idea of accepting pain. To be able to have everybody get better and like ACT more, even when we’re saying accept pain, it seemed pretty mind-boggling at the time.

I know you do a lot of work with anxiety as well. Has had there been similar studies that found ACT to be more satisfactory for anxiety versus traditional CBT or is that something that you’ve experienced in the clinical setting?

It’s a great question and I don’t know. We did do one other study at that time that was for older adults with generalized anxiety. I want to say that there was a similar finding, but it was a long time ago. I don’t remember so I’m not sure in terms of the research, whether that’s been something consistent, but I have certainly found anecdotally and in my clinical experience that people do tend to gravitate toward ACT for two reasons. One, the focus on values, the idea that you can live an incredible, meaningful, bold life even with the pain that comes with it. In fact, if you don’t have pain, then it’s probably because you’re avoiding the things that matter to you. You wouldn’t be anxious about it if you didn’t care about it.

It’s also because it’s a lot of hard work to try to fight to change your thoughts and your feelings. It can feel exhausting. There’s something that people experience as almost liberating when they’re given permission to respond to their internal experiences in a different way like, “It doesn’t mean that I’m broken because I have this internal discomfort and that it’s my job to change it and when I can’t change it, I’m failing in some way.” To have this, “This is part of being human and I can choose to respond to it differently and still have a big life.” There’s some liberation around that almost. People do connect with the treatment quite powerfully.

I’m curious from a psychotherapy perspective as a licensed mental health professional, is there that sigh and that liberation for practitioners as well when they start to understand the difference between traditional CBT versus what ACT can do for a client?

That has certainly been the case for me. When I’ve done teaching, training, and supervision or I’ve talked to other clinicians who have found ACT, that seems to be the overwhelming message. Most anyone I know who does ACT as a practitioner embodies ACT in their own lives and in their own experience. That answers that question in its own right. All of our lives have been powerfully changed because of living ACT and that speaks volumes.

You could have written many books, you’re an expert in anxiety. Why The Big Book of ACT Metaphors? Why was that important for you at that time?

At the time, I remember when I was learning ACT and doing ACT and that experiential practice component is important and powerful. I would be preparing for sessions thinking, “I’m probably going to be talking about acceptance or diffusion. What might I want to use as an experiential practice?” Early on, when I’m first learning these things, I don’t have it all in my own memory bank. I need some assistance with scripts or other people’s ideas. They were all spread across multiple different books. I know that there’s this tug of war exercise, but I don’t know where it is or which book. I heard it somewhere but I don’t know where. I thought, “Wouldn’t it be nice to have one book that you could pull off your shelf and flip to diffusion and have a bunch of ideas to choose from?” It didn’t exist and I thought, “Maybe I could write that book.” It seems very ambitious because I had no experience in writing books. I contacted Niloofar Afari, who’s my co-author. She was a former supervisor of mine and also an ACT expert. She agreed to work on the project with me and the rest was history.

You have a beautiful book. It’s almost 200 pages. There must be hundreds of metaphors in here for all the six processes. In general, to support psychological flexibility. Can you describe what psychological inflexibility is, how that relates to human suffering and why that is the entire undercurrent that ACT puts forward?

Psychological flexibility would be the idea that we can show up to whatever is present in this one moment, primarily inside the skin, but also outside the skin, but thoughts and feelings and make space for all that’s there. To be open and aware to notice those experiences and to do what matters. It’s allowing those experiences fully without defense when what we might normally do is work very hard to suppress those things or push them away because they’re uncomfortable and we don’t want them. We might just do what our mind is telling us even if those choices are moving us away from what matters or our values. Psychological inflexibility would be letting the thoughts and feelings be in charge and dictate what we’re doing, even if that’s pulling us away from what matters. The idea in ACT is that psychological inflexibility is the root of all of our issues and problems.

As you’re talking about thoughts and feelings, the feelings part could be an emotion but it could also be a physical sensation in your body, right?

Absolutely. It could be physical sensations, emotions, urges, anything that’s happening inside the skin and any kind of thoughts as well.

With regard to the language, ACT is really the language and we’re talking about metaphor, which includes language. We need language and it’s what’s important in the therapeutic relationship. How does language get people stuck in the pattern they’re in?

Language is thought to be the culprit for what creates psychological inflexibility. The idea is that as humans, we’re the only species that has language. One of the examples I like to use and this isn’t mine, I might have gotten this from one of the Hayes’s original Get Out of Your Mind and Into Your Life, I’m not sure I’m citing it properly. For example, you were locked in a room and you can’t find your way out. We have these higher language abilities, we can generate potential problem-solving strategies. We might make a phone call. If we don’t have cell service, we might yell, scream or bang on the window. We might break the window with a piece of furniture and climb out. There are numbers of things we can do. Even if we’ve never been in a locked room before, we have these analytical abilities where we can solve this problem whether we’ve ever had that experience or not. This is adaptive and what puts us at the top of the food chain.

If there was a cat stuck in that same room, it would starve to death unless someone found it. The problem that arises is we use those same skills to solve “problems” that are inside the skin and that we often rely on language. For example, assumptions, predictions, or rules to make choices about what we want to do or not do in the absence of direct experience. If you have been to the mall and had a panic attack and you think, “This is a huge problem I have to solve,” it’s your fight or flight. It’s your body saying you’re in danger and you think through your options. One option is to take Xanax, drink alcohol, leave, escape, runaway and that’s going to work.

Your mind can start generating all information about how malls are dangerous and crowds are dangerous. The way to prevent this problem from happening in the future is to not go into those situations again. This is a trap because those situations aren’t dangerous and in fact, escaping the mall isn’t what cured the panic attack. It’s time that cured the panic attack. If you had stayed in the mall, the panic attacks still would’ve gone away. It’s because the mind says escape, we then attribute the reason to something different. We’re able to make all of these connections after the fact that then influence our behavior the next time and the next time, even when we do not have that experience at that moment.

It’s a beautiful example. It’s very in line with chronic pain as well, because with chronic pain, often there is that fight or flight response and your brain thinks that there’s some harm potentially that’s there, but it doesn’t exist. The brain does wonderfully descriptive things to turn on that response. It could be sweating, it could be anxiety, it could be pain. Many different things happen. It’s amazing how the brain can send a signal on many different ways that relate almost like trans-diagnostically to all these different types of conditions that as humans, many of us experienced naturally. Tell me about experiential practice because ACT, many of the third wave psychologists do this and mindfulness in general does, but how has ACT embraced experiential practice?

The reason that experiential practice has become so important in ACT is that it’s seen as the antidote to this language problem. If language is the thing that’s keeping us stop, that’s making us psychologically inflexible, that psychotherapy is talk, it’s even called talk therapy. How do we get around these traps of reasons, rules, assumptions and predictions if what we’re doing is talking? With ACT, we use these experiential practices, whether it’s metaphors or active exercises in the session that are aimed at putting people in touch with elements of their actual lived experience as a way to get away from the language piece. The way that we traditionally think of this is with the metaphor, the tug-of-war exercise or these kinds of things.

The experiential piece of ACT can start right with the very first question that a therapist asks the client irrespective of discipline. For example, if I were to say, “Do you think that when you ask your spouse to have your needs met that he won’t like you as much?” That puts you in the position to give reasons. It’s giving more worries or assumptions about things. That’s language, that’s not experienced. If I say, “When you go along with what your spouse says and you don’t ever ask to have your own needs met, does that make you feel closer to him or do you notice more distance in your relationship?” The way the question is being asked elicits an answer that’s based on a lived experience. You can start right from the beginning.

You mentioned the tug-of-war. What are some metaphors that you find work well? Let’s take anxiety first because anxiety is one of your interests. What are the metaphors they use in practice?

The one that I like the most and this probably relates to pain as well. This isn’t mine. I believe Steven Hayes originated this. It’s the idea of some anxiety or stress detector machine. I hook you up to this machine. It’s like a lie detector, except it registers how anxious or stressed you’re feeling. As long as you don’t get anxious, you’ll be totally fine. If my machine registers at a certain level, it’s going to deliver a lethal shock and you’re going to die, just don’t get anxious and you’ll be completely fine. What’s going to happen?

You’re going to get shocked.

You’re anxious, you’re shocked, you’re dead. If you think about the reason why that’s happening, it has everything to do with your relationship to anxiety because you’re now saying, “Anxiety is horrible. It’s terrible. It’s dangerous. It will kill me. I can’t be anxious.” You’re now anxious about anxiety. It’s this idea that as long as you’re unwilling to have it, you’ll have it. Therefore, the antidote then isn’t, “I must make all this anxiety go away because it’s bad and dangerous,” because now you’re anxious about anxiety. It’s, “I need to change my relationship to anxiety and learn how to make space for it and allow it to be present.” When I let go of the struggle, that’s the place where people go, “If I’m willing to have it, then it will go away?” No, that’s not how it works.

If you’re unwilling to have it, it’s there. If you’re willing to have it, it will do what anxiety does, which is ebb and flow, come and go. Pain is probably similar and it may not be if you’re unwilling to have it, you have the pain. You have the distress associated with the pain. A lot of the ACT studies around pain will show that if you compare acceptance to suppression, the actual physical experience doesn’t change. If there’s acceptance, there will be pain. If there’s suppression, there will be pain. The thing that does change is the distress and the anxiety about having the pain. The attention and those kinds of things are better in the acceptance condition than the suppression.

The physical versus the emotional aspects of pain. We often say the clean versus the dirty.

That lie detector or anxiety detector, that metaphor could translate well to pain as well if you’re talking about that dirty pain.

There’s a metaphor of yours that I’ve used with clients that’s worked well and it’s in your ACT book. Maybe you want to share with us. It’s the metaphor about juggling or circus metaphor.

That is one of the few that I made up myself. One of the things that I love about this book that makes it special is that the majority of the exercises in it came from the ACT community, the CBS community, the Association for Contextual and Behavioral Science. Niloofar and I reached out to the community, asking if people wanted to share some of their favorite experiential work. She and I wrote the guts around what all the processes are in that kind of thing. The actual exercises themselves, the majority come from the community. It was a cool experience to gather all of that information. It feels like it was a collaborative effort. The juggling metaphor is one that I did create. This is the idea that we believe we can control our internal experiences because sometimes we can. There may be things you can do to limit the amount of pain that you’re feeling or to control the anxiety or whatnot.

In many ways, it’s like juggling. Anybody can toss one ball up and down with one hand. Many people can even toss two balls or juggle two balls. You get to three, four, five and six, the more balls, objects, or whatever you add into the juggling. Before long, all of your energy, effort and attention can only be on this one place and nowhere else. It becomes difficult to keep up this juggling act. Eventually, all of the balls come crashing down. This is our internal experiences. We may have this perception that we’re doing a good job of keeping all of the stuff in check and maybe to some degree we are. It takes a lot of effort. It often takes all of our attention, which means our attention isn’t on other important areas of our lives. Often eventually they come crashing down and not only do we still have those internal experiences to deal with, but a big mess of balls that we have to clean up on top of it.

At the end of that metaphor, you say that one of those balls may even potentially hurt you or harm you, which is important. The reason why I love that metaphor about the juggler is that people with chronic pain are on a mission to find a “cure.” With that, they collect, “I’m going to meditate for twenty minutes every day. I’m going to do my progressive relaxation exercises. I’m going to make sure I take my supplements.” Sometimes it’s one supplement, sometimes they’re many. Some of these are very valuable health-promoting behaviors, but the constant struggle of collecting all of those types of interventions and then squeezing them into your life, that control agenda can backfire on someone. That’s why that metaphor has helped me with a lot. Thank you for that metaphor. It has helped me with a lot of patients and they realize, “Maybe I’ve taken things that are very good and now I’m using them in a way that’s not beneficial for my health.”

When I was newer to ACT, an important a-ha moment for me is when you’re first learning ACT, you maybe have this idea of you have to get rid of all of the control stuff. That’s not the case. There are examples of experiential avoidance or control that they might count as the definition. Experiential avoidance is anything you’re doing to change and control your internal experiences. Whether it’s water therapy, PT, medication or whatever it is people doing, they technically do fit that definition of experiential avoidance. Experiential avoidance is only “bad” if it has a cost. When I was doing ACT for chronic pain, the thing that landed powerfully for me was what we’re talking about here is balance.

I’ll give you an example of a client I had. I tell his story all the time, which he doesn’t know. He was someone who had been a big basketball player. He had an accident, an injury, and he was paralyzed from the chest down and was in a wheelchair. He was in severe chronic pain for decades. When he came to us, this was before the opiate crisis and he was on an immense amount of prescribed opiate medication. He was cognitively quite out of it. Our clients in the group would ask this question like, “Are you saying we have to stop all our medication and we have to stop doing all these things?” I’m like, “No, of course not.”

If you stopped all your medication, would that allow you to live your best life? No, because you’d be immobile. For him, this specific example, was how we could bring the dose of those medications down so that you’re alert, awake, and can participate in your life? That means there’s probably going to be an increase in some breakthrough physical pain. You’re going to stay on whatever dose of medication where we can find that balance, where you can be awake, alive, and participate while still probably feeling some pain. We’re not going to take them all away because that wouldn’t allow you to be alert and to participate. The same would go for all of the other things, the acupuncture, chiropractor, PT and all of these things. Let’s do a cost-benefit analysis like to what degree are these things helping versus how much time and energy are they taking? How is that adding to or taking away from the other areas of your life that are important, playing with your grandkids, working, or whatever it is that the people want to do? It’s not no control, but it’s finding that balance so you can live your best life.

I like that, live your best life, but that’s also workability in the ACT model.

What ended up happening with this particular person is because he could no longer play basketball, he felt like his life was over. There were no options if he couldn’t play basketball. What we talked about in terms of values were what it was about basketball that got your juices flowing? What mattered to you? Was it the teamwork? Was it the competition? Was it the strategizing? We worked through this because he physically could not play basketball, not even in his wheelchair. What he ended up doing was becoming a coach and this was not less painful. There was more physical pain because he had to reduce his medication. There was also emotional pain because he had to sit on the sidelines watching other people do the thing that he desperately wanted to do but couldn’t. What he got in return were all other amazing things. Being able to lead a team and participate in basketball again. Whatever pain he had as a basketball coach was far more tolerable and worth it than being home alone and doing nothing with no one.

It’s a great transfer of someone’s values from one place to the next. What’s interesting too is I know maybe it’s a little bit different in psychotherapy, but you often don’t see patients or clients months or years after to see how they take that work and what happens to their life. That example, you happened to probably work with him for a while where you can see how he was able to find his values in other areas of his life, which is interesting.

He made that change relatively quickly too. What I often found doing ACT for pain groups is it would take a few weeks before it clicked. I remember as a clinician, I’m always feeling like, “They’re not getting it. How do I make them get it?” Letting go of that a bit and sticking with them trying to get more psychological flexibility here. It just clicks at some point down the road and they start making these powerful changes quite quickly. A lot of that is because of the experiential practice and especially for these pain folks in particular who came in off and on a lot of medications initially. There’s no way we’re going to be doing typical CBT worksheets, trying to do a lot of heavy intellectual debating of thoughts thing. There was a minimal amount of psycho-ed. It was more about relying on experiential practice that people got it in a lived way rather than an intellectual or academic way.

How can practitioners begin to develop their own metaphors in practice when they’re working with clients? They can purchase your book and start there because all of us go through all these ACT books and consolidate them. You did that work for us, but how can someone begin to create their own metaphors as they become more proficient?

Probably a key is I always try to be aware of new clinicians where the most common question I get is, “Tell me exactly what to say in session one.” When you’re feeling insecure and anxious about something you’re not an expert on and you want the exact script of what to say and how to say it. It doesn’t quite work that way. With the metaphors in experiential exercises, those are some scripts so that you have a little bit of help there when you’re first getting started. You want to be careful not to over-rely on those things or just throw those things out there in session because you’re avoiding your own anxiety about doing ACT.

Once there is a little bit more proficiency, a couple of things. One is there are four elements that we’re looking for in the room. One is what the pain is? What is the emotion, the physical sensation, the thoughts, etc.? We want to understand what the pain they’re experiencing is. What’s the behavior that they’re engaging when that pain shows up? What are they doing or not doing? What’s the function of what they’re doing or not doing? What do they get when they avoid that situation or drink alcohol? Finally, what’s an alternative? If we determine that what they’re doing or not doing is psychologically inflexible, that it’s a way to avoid what they’re feeling and it’s pulling them away from their values and what matters then what’s an alternative that they can be doing.

As long as the experiential practice is geared toward either uncovering the pain, the function, the cost, the values or suggesting an alternative, then anything you do that can get at those things, you’re right where you need to be. That’s making the experiential work functionally similar to what’s going on with your particular clients as opposed to just pulling it out of a book. The other way that we can amp these up is to try to make them topographically similar. For example, I have a client who’s an avid rock climber. When I talked to her in metaphorical ways, I’ll often talk to her with rock climbing lingo. I’m not a rock climber, I don’t know rock climbing lingo. I’ll do the best I can. I’m like, “You use the carabiners. Is that the right word?” I’ll have to check in with her. What’s great about that is she fills in where my language might be a little bit off, which makes that experiential practice or metaphor even more powerful for her because she’s thinking about how what we’re talking about applies to something that she does in her real life.

When you’re listening, you have one ear open and all the time listening for the metaphor that your client is using. Are you listening for, I don’t know if this is the right terminology, but both the positive and the negative metaphors that they’re using?

What do you mean by positive and negative?

Let’s take the rock climbing example. “When my anxiety gets bad, I feel like I’m falling off a big cliff,” versus, “I had such a good day. I felt like I could race to the summit in a matter of moment.”

Absolutely. One of the greatest things is when they start talking in metaphor. They generally don’t when they first come into therapy. When they start speaking in that way, I think, “There’s something that’s getting through here.” This is another one I love for pain that’s related to what you were saying about the juggling. This is an older metaphor from the original ACT textbook in ‘99, which is the idea of the shovel. You’re in a hole and it feels like you’re in a hole when you’re struggling with pain and you think, “If I just had the right tool, I could get myself out of this hole.” You grab a shovel and you start digging. When you’re standing in a hole and you use a shovel to dig, what happens?

You get a bigger hole and you go down deeper.

You think, “The problem is I don’t have a good shovel. I need a better shovel.” You trade in your cheap Home Depot shovel for a gold shovel and you keep digging. You can take this metaphor on and on out a bad shovel. “I need a diamond encrusted shovel or a platinum shovel.” This can be compared to, “If I just find the next best treatment to get rid of my pain. Maybe the acupuncture wasn’t the thing. I’ll try the chiropractor next.” What I love is that you could be twelve sessions in and you know your client has got it, but we’re human. We don’t want pain. They might come in and say, “Have you heard about spinal stimulators? I found out about spinal cord stimulators and I think I finally found the cure to my back pain.”

For me, inside I’m thinking, “I thought you had it, but apparently you don’t have it,” but they do. It’s this human thing. We have to return to acceptance again and again. At that moment, all you have to say is, “It sounds like you picked up another shovel.” That handful of words is all it takes for the client to go, “I picked up another shovel.” They get it instantly because what these metaphors do is they make all of this salient, memorable, and easy to internalize as opposed to a whole bunch of talking around looking for another cure to your pain.

That’s a powerful way to communicate with patients. It’s so important.

If you make up one that’s relevant to them specifically, then it seems to be even that much more powerful or I’ll extend the metaphor. Using the rock-climbing example, one of the things I was talking about with this client was a cultural issue where she had traditional and conservative parents who thought she should be cooking for her husband more. She doesn’t cook and her husband doesn’t want her to cook. They had different cultural values and whatnot. When we were talking about rock climbing, I said, “If your mom said, ‘When you find your next finger hold, you need to grab on as tight as you possibly can so that you don’t fall,’ would you listen?” She would say, “No, because the harder you grip, the more tired you get and then you won’t be able to make it to the top.” Later something came up. I don’t remember what it was but about the parents. I thought, “Did your mom climb on your back? Was she on your back telling you where to put your foot on your next step?” You come right back to the principles you’ve been talking about with that one vivid image.

I love metaphors and it’s so important in pain as well because people start to talk about their pain metaphorically. All the information in your book is important. Speaking of acceptance, I know you’re working on a new pilot study that looks at exposure in patients with fibromyalgia. Exposure is a word that’s a synonym for acceptance. I know that study is not out yet, but can you tell us a little bit about that study?

This is a study that would be considered more in the CBT realm of things. It’s a study that’s being done at San Diego State University. It’s looking at women who have been diagnosed with fibromyalgia who have also been found to have a fear of movement and some anxiety around pain and movement. There’s been a lot of life restriction essentially. What the study is looking at is taking a traditional exposure-based idea. If someone has a phobia of spiders and we gradually expose someone to a picture of a spider, then a video of a spider and then a small live spider, and eventually you’re playing with a tarantula. It’s taking that paradigm and applying it to movement. The therapists, together with the patient or client, create a hierarchy.

What are the things you’re not doing? What are the things that you’re avoiding but things that you maybe would like to be doing or things you were doing before you were diagnosed with fibromyalgia or the pain became more severe? It’s creating a stepped exposure plan for doing things that feel a little scary but not too scary. Looking at before the exposure session, what is it that you’re afraid will happen? What is your mind telling you? If I go hike this rocky path, then what’s going to happen? That’s the prediction. They go do those exact things and then looking at what’s the outcome. What actually happened? What your mind is telling you and your experience. Do those two things match? This is back to the language issue in ACT, language versus experience.

In the CBT world, one of the things Michelle Craske discovered is that the situation, which was thought to be the most important element of exposure isn’t the predictor of outcome. Whether you habituate or not doesn’t predict whether you do well in exposure. It’s the new learning that takes place when you look at what you think is going to happen and what happened don’t match or even if what you’re afraid to happen, happens. It’s never as bad as you think and you can handle it, you can cope with it, and it’s not as catastrophic. That’s the study that I was working as the clinical supervisor of the therapists in the study. It was being compared to a control condition that was a nutrition education.

When we were doing it, it was a pilot study and then the data we’re going to be used to apply for a larger grant to do a full RO1, do a full randomized controlled clinical trial. None of those data is published yet, but the results were looking quite promising. As the supervisor who was listening to audio tapes and talking to the therapists, anecdotally the empowerment was very high. The women were all doing quite a lot more and feeling a lot better about the fact that they were doing more. They’re realizing that a lot of the ways in which they were limiting themselves weren’t necessary. Their predicted outcomes about what would happen if they walked up to the stairs, didn’t use a railing, walked on a hiking path instead of a track. The things they were afraid would happen really didn’t happen.

It sounds like more traditional CBT graded exposure, hierarchy exposure-based approach, but you brought in some of, “What is your mind telling you?” which brings a little bit more of the mindfulness acceptance part of it.

That wasn’t part of the study specifically. This is where these two things overlap. We might be speaking slightly different languages, but we are looking at many of the same things. This is why there’s this movement now toward more processed-based therapy. Steven Hayes is known as the Founder of ACT and Stefan Hofmann is a big CBT guy. They used to sit on panels and debate my way versus your way. Now they’ve written a book together called Process-Based CBT and looking more at the mechanisms that we know research is finding or what we need to tackle.

All roads are leading to Rome as they say. Tell us what you’re working on new.

I’m done working on it, but it’s in the midst of not yet out. I have a book that’s called Be Mighty and I’m very excited about it. It’s an ACT self-help book for women with anxiety. It doesn’t come to print until January of 2020. It’s only available for pre-order. It’s taking all of the ACT principles and any women who are struggling with stress, worry, anxiety, panic, OCD, PTSD. Possibly even pain because pain often comes with anxiety and mood issues, but not looking through a pathologizing lens. It’s this changing your relationship to these very normal human experiences and focusing on the me that you want to be and the values and I hope, more uplifting, empowering. It’s also a funny and humorous way of changing your relationship to anxiety and being the woman that you want to be and having a life that you want. I’m excited for that to come out. It will take a while.

I love the title Be Mighty. It’s going to resonate with a lot of people. Why that title versus like 50 Ways to Ease Your Anxiety? I would like to have a whole bunch of ways to ease my anxiety, but to be honest, I’d rather be mighty.

The title was the very first thing I thought of and that was a few years ago. I don’t know how to answer the question, why or where it came from? It’s one of those things that came to me like a calling, like this is a book I have to write. The title was the first thing and I initially had wanted it to be or I envisioned it as a general ACT self-help book. When I talked to my publisher about it, what they educated me about, which I didn’t realize is that you have to be able to answer these questions like who is your audience? People who are buying the book, the book needs to speak to them. They have to know that that book is for them.

The publisher suggested that it has to have a little bit more of a niche. At that time, it wasn’t the book I wanted to write. We took a bit of a break. Long story short, without giving all the details, I suddenly had this epiphany that I wanted to write a book that was specifically for anxiety, given that that’s my area of expertise and always has been. That was the next proposal and they said, “Great, let’s do it.” Right then, John Forsyth’s book came out, 52 Ways To Find Peace of Mind. It’s a great book, but it felt a little bit too similar to what I was proposing.

It was Catharine Meyers at New Harbinger. I can’t take credit. It was her idea. She said, “I have been thinking about maybe writing it for women.” It was one of those things where I got goosebumps from head to toe. I myself over the last few years, with the political climate and everything, has become much more of a feminist than I ever realized I was. I’ve been struggling a lot myself dealing with issues of sexism and oppression. It has become something that has gotten much closer to my heart in the last couple of years, but I don’t see myself as an expert in gender issues. It wouldn’t have occurred to me to think I could be the person who wrote that book. When she brought up that idea, it was like instantly this was the book I was always meant to write. If I had thought of it a few years ago, it wouldn’t have been the right time. It felt like the universe was making it happen exactly when it needed to happen. Women need to feel mighty right now more than they did a few years ago.

That’s why I love the title and especially in this political climate. It can be very triggering for people with chronic pain in a lot of different ways. There are certain aspects of the administration that hasn’t been kind with regard to certain health challenges. That title, Be Mighty, will be mighty successful for you because people are looking for that message. Jill, it’s been great chatting with you. You can find Jill’s book, The Big Book of ACT Metaphors on Amazon and then go on and pre-order Be Mighty. I know you run the Center for Stress and Anxiety Management in San Diego. Tell everyone how they can learn more about you.

I have a website. You can either go to my clinic’s website, which tells you all about my practice and all the incredible talk about mighty women who work for me. They’re amazing. That’s CSAMSanDiego.com. I started my own website, which is still a work in progress. It’s getting ready for the book to come out, which is JillStoddard.com. You can find out about me in either of those places and where the books are available. I also do a lot of podcast interviews. I’m also a peer-reviewed ACT trainer. I do a lot of workshops, teaching, training, and other public events. I’m happy to talk with people about any of those things or professional consultation as well like supervision, but consultation for therapists.

I want to thank you for being on the show. I want to thank you for joining us on the show. Share this out with your friends and family. Make sure to hop onto the website IntegrativePainScienceInstitute.com and sign up for the newsletter. It’s a pleasure being with you.

Important Links:

• Center for Stress and Anxiety Management
• The Big Book of ACT Metaphors – Amazon
• Be Mighty: A Woman’s Guide to Liberation from Anxiety, Worry, and Stress Using Mindfulness and Acceptance – Amazon
• www.IntegrativePainScienceInstitute.com/139download
• A Randomized Controlled Trial of Acceptance and Commitment Therapy and Cognitive Behavioral Therapy for Chronic Pain
• Get Out of Your Mind and Into Your Life
• Process-Based CBT
• 52 Ways to Find Peace of Mind
• JillStoddard.com
• IntegrativePainScienceInstitute.com
• https://Twitter.com/CSAMSanDiego
• https://www.Facebook.com/CSAMSanDiego/
• www.CSAMSanDiego.com

About Jill Stoddard, PhD

Jill Stoddard is the founder and director of The Center for Stress and Anxiety Management, a multi-site outpatient psychotherapy clinic specializing in Acceptance and Commitment Therapy and Cognitive and Behavioral Therapy for anxiety and related issues. Dr. Stoddard received her Ph.D. in clinical psychology from Boston University where she trained at the highly regarded Center for Anxiety and Related Disorders under the leadership of Dr. David Barlow and mentorship of Dr. Stefan Hofmann.

She completed her APA accredited internship and post-doctoral fellowship at UCSD’s School of Medicine Department of Psychiatry. She is an award-winning teacher and peer-reviewed ACT trainer. She has coauthored articles on ACT, CBT, anxiety, trauma, and pain.

She also co-authored The Big Book of ACT Metaphors: A Clinician’s Guide to Experiential Exercises and Metaphors in Acceptance and Commitment Therapy; her second book, Be Mighty: A Woman’s Guide to Mastering Anxiety, Worry, and Stress Using Mindfulness and Acceptance, will be published in January 2020. She is active in the Association for Contextual and Behavioral Sciences and is a co-founder and vice-president of the non-profit San Diego Cognitive Behavioral Therapy Consortium.