Intervention (Hidden)
Intervention Module
The intervention model for the SS-ACT therapy proposed by Esawara-Murthy (2020) was utilized with slight modifications. Esawara-Murthy’s SS-ACT originally incorporated six core processes of ACT—acceptance, cognitive defusion, mindfulness, self-as-context, values, and committed action—based on the Hexaflex model (Hayes, 2004). However, in the current study, the model was adapted to align with the Triflex model (Harris, 2009a), which simplifies the Hexaflex framework into three main pillars: Be Present (contact with the present moment, self-as-context), Open Up (defusion and acceptance), and Do What Matters (values and committed action).
Additionally, while the original model of SS-ACT was designed to address shame and experiential avoidance (Esawara-Murthy, 2020), the current study introduced modifications to tailor the intervention for anger management. Specifically, certain exercises targeting shame were replaced with those more suited to addressing anger regulation and emotional flexibility. The content for experiential avoidance remained the same but was adjusted to focus on anger rather than shame. Furthermore, the current study focuses on both anger and experiential avoidance, emphasizing their interplay within the framework of psychological flexibility.
Structure of the Session
Duration: 90 Minutes
Goal
The goal of the therapy is to promote psychological flexibility for anger, and experiential avoidance through being open up, fully present and engage in values driven behaviors.
Introduction (15 Minutes)
Initially, the therapist conducted a general assessment of the client, evaluating their perception of their symptoms as problematic. As ACT primarily focuses on acceptance of difficult emotion and making committed action based on valued living, therefore, after initial assessment, the client were ask about their willingness to work on their difficult emotions and follow the therapeutic intervention. Their willingness was taken through the following exercise for taking their commitment to change.
Exercise 1: The Willingness Dial
The students were asked to imagine you have dial through which you can show how much you are willing to accept or allow to experience difficult emotions without try to avoid them.The dial wouldn't help you to have control on the intensity of your emotion, rather it will simply show how much you are open to accept the emotions.
Low on the Dial (0-2). The number from 0 to 2 indicate the minimum or low willingness to experience emotions. You are preferring to avoid the feelings (e.g. you try to distract yourself, or suppress your feeling or lash out).
Middle on the Dial (3-5): The numbers from 3-5 indicates that you are moderately willing to experience your emotions. There is some probability to change your emotion in certain point.
High on Dial (6-10): You’re fully willing and open to experience difficult emotion (anger) without any effort to change it. You are familiar that emotion can exist without you reacting to it or allowing it to control your responses. Those clients who showed positive response or rated between 6-10 were further taken to other steps of SS-ACT.
After obtaining informed consent for the therapy, the therapist firstly, provided psychoeducation to the clients, explaining that experiencing stressful events is a universal human experience and in response to these stressful events, the emotional responses such as anger, shame, and guilt are natural. However, these emotions can become maladaptive when their intensity, frequency, and duration increase, eventually solidifying into unhealthy behavioral patterns if left unaddressed.
The therapist then introduced the five components of anger to the client:
Pre-Anger Feeling: This stage involves experiencing underlying emotions such as pain, guilt, and shame in response to a traumatic event.
Triggering Thought: At this stage, the client interprets a situation as threatening, which acts as a catalyst for anger.
Anger Feeling: The fight-or-flight response is activated, leading to physiological reactions such as trembling, shaking, rapid breathing, and an increased heart rate.
Impulse to Act: The client experiences a sense of being on "auto-pilot," feeling compelled to act out their anger.
Anger Expression: In this stage, anger is either acted out (e.g., shouting, blaming, or hitting objects) or suppressed (leading to emotional numbness and internalized distress).
The client were also introduced to the cycle of anger, which consists of five stages: triggering event, negative thoughts, emotional response, physical response, and behavioral response. Additionally, the therapist explained that in response to traumatic events, individuals often develop experiential avoidance as a coping mechanism. This involves avoiding distressing thoughts, feelings, and emotions in an attempt to escape painful memories. While experiential avoidance may provide temporary relief, it ultimately worsens psychological well-being over time. Therefore, it is essential to confront these emotions rather than avoid them.
The therapist then linked the fight-or-flight response to both the cycle of anger and experiential avoidance, helping the client understand the physiological and psychological processes involved. The the client were engage in first part of the therapy i.e. being open.
Table
The Following Table is Showing the Structure of SS-ACT
Phases Aim Intervention Content and Exercises
Introduction
General assessment, Informed consent, limit to confidentiality
Defining Anger and Experiential Avoidance (15 Minutes) The aim of the first step was to provide debriefing and psycho-educate the client two possible responses for trauma i.e. Anger and Experiential Avoidance Informal assessment
The willingness Dial Exercise for seeking consent to start intervention
Psycho-education: Defining anger and Experiential Avoidance
Open up
Acceptance (10 minutes) Developing willingness as an alternative to suppression
Acknowledgment of aggression and physical sensation associated with it Things you can control and you cannot control along with Tug of War Exercise
Anger as a Cloud
Defusion Training (15 minutes) Noticing thoughts as barriers to
action I’m having thought /Leaves on the stream
Say Though Aloud
Being Present
Self as context Differentiate between noticing and observing self The chessboard Metaphor
The Witness Anger Exercise/ Stream of Consciousness
Contact with the present moment Being fully aware Grouding Technique
Leaves on Stream
Do What Matters
Values clarification (10 minutes) To clarify what matters to clients in
order to identify a hierarchical
motivator to sustain behavior
change Values card sort
My super Hero
Committed action and rounding up (15 minutes) Encourage workable behavior
change The SMART Goal
The 10 minutes rule
Part 1: Being Open
The first pillar of the therapy is known as being open. It comprises on two elements i.e. acceptance and cognitive defusion.
Acceptance (10 Minutes)
The clients were explained that difficult emotions like anger are valid and natural. However, avoiding it or struggling against it often make it worst. Therefore, the aim is not eradicate the anger but change the relationship with it.
The clients were asked how do you normally respond when anger arises? Do you try to get rid of it or avoid it? This question brought experiential avoidance into focus and illustrate how avoidance strategies often fuel more anger. Then the clients were psycho-educated that how acceptance to these difficult emotions can make change in reaction. The concept were made comprehensible through two exercises. These exercises are listed below.
Exercise 1: Tug of War
It was explained to the client that imagine you are in tug of war with a big ugly and very strong monster (i.e. your anger). In between you and the monster, there is big pit and one you will fall if lose the war. Imagine you are trying to pull the rope, but the harder the monster pulls, you get closer to the pit.
The monster has endless energy but you are tired after a certain point of time. You can clearly see that you will lose the war. So what alternative do you see in the entire circumstance (This will develop an insight for acceptance). This thought provoking exercise brought acceptance for not pulling the rope may save from adverse fall. Dropping the rope may help you to fall in the pit. Therefore, the alternative to struggling with difficult emotion like anger is taking a stance for acceptance towards emotions, body sensation and thoughts.
Then the concept of acceptance was further clarified that sometime the word acceptance sound negative. However, acceptance doesn’t mean tolerating unnecessary pain or admitting defeat. Rather acceptance is willingness to experience uncomfortable emotion (anger) to access something better in life. Its about feeling what you feel when you feel it. If you learn the art to tolerate feelings of anger then you don’t have to suffer from suppressed anger and develop much more flexible set of actions.
Exercise 2: Anger as a Cloud
Anger as a cloud was another alternative activity for acceptance that was used with some students. The clients were instructed to close their eyes and imagine their anger as a storm cloud. Rather than trying to push the cloud away or change it, ask them to simply observe it, letting it pass through the sky of their mind. The cloud may stay for a while, but it doesn't have to control their actions. To encourage acceptance by allowing the client to sit with the feeling of anger without reacting to it.
Cognitive Defusion
The meaning of cognitive defusion was explained to the client. It means separate you stuck thought by recognizing that thoughts are just words rather than the truth. In other words the defusion refers to stepping back from the difficult thoughts and observe them as creations of the mind. The client were asked about the thought prov-k