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Mindfulness, Acceptance, Bibliotherapy and Research: A Q&A with John Forsyth, PhD

Mindfulness, Acceptance, Bibliotherapy and Research: A Q&A with John Forsyth, PhD

Editor’s note: The following is an interview with John Forsyth, PhD, one of the authors of the bestselling Mindfulness and Acceptance Workbook for Anxiety: A Guide to Breaking Free from Anxiety, Phobias, and Worry Using Acceptance and Commitment Therapy, which has recently published in its second edition.

NH: The Mindfulness and Acceptance Workbook for Anxiety has sold more than 125,000 copies. What makes the approach used in this book unique?

JF: When thinking about what is unique about the workbook, an image came to mind of an uncommon clinical encounter. Imagine, for a moment, this scenario:

A client comes in to see you.  It’s your first meeting. You know little about why they are seeking help at this time, so you ask, “What brings you in today?

The client responds,I feel anxious more often than not. My mind races, full of disturbing and scary thoughts. I’ve had a few panic attacks too. At times I feel short of breath, and at other times I feel a sinking feeling in my stomach.”

She goes into more detail about her experience with anxiety and fear; covering anxious thoughts, feelings, and bodily sensations, and some of the situations where anxiety shows up. Much of this is familiar to you, especially if you’ve worked with other clients suffering with anxiety-related disorders.

When the client finishes describing her experiences with anxiety and fear, you interject in a gentle and empathic way, saying It sounds like you’ve been struggling with anxiety and this is very difficult for you.”

The client, looking a bit perplexed at your comment, replies Well, this stuff used to keep me stuck and struggling, but not anymore.”

Caught off guard, you follow up with I’m a bit confused, can you tell me more about that?”

The client goes on to say,Well, I don’t resist or avoid my anxiety and fear like I used to. I am open to it when it shows up and meet it with kindness and gentleness. This has created space so that I can focus on doing what matters. In fact, I am now living my life as wholeheartedly as I know how, and with my anxious mind and body.” She gestures by opening her arms wide.

Now, you find yourself even more confused than before, thinking why would this person be coming in to see a therapist like me?  And so you return to your original question, so, I’m still a bit confused about what’s bringing you in today?”

The client responds I’m here to share something that I think will help you in helping others. I used to see my anxiety and fear as a problem. In a way, I was fighting a war with myself, turning away from just about anything that might trigger anxiety, fear, panic, and discomfort. I avoided. I distracted. I tried to cope. I self-medicated with alcohol, the Internet, and TV. I argued. I withdrew. I’ve been in and out of therapy over the years, always looking for ways to beat this, to manage it, to make it go away. Over time, my life shrunk to the size of a postage stamp and the anxiety and fear just kept growing bigger and bigger. I had had enough of being bullied around by my anxiety and fear. This is when I stumbled upon this new workbook called ‘The Mindfulness & Acceptance Workbook for Anxiety,’ or something like that.”

She goes on to share how the workbook was new, different, and life altering.

The workbook taught me that anxiety and fear are not choices. But I can choose how I relate with them, just like any relationship with another person I suppose. Before the workbook, I was very unkind with myself and my anxious mind and body. I thought that to be happy, I had to change what I was thinking, feeling. But inside all of this was the message that something is wrong with me. That I was broken. And that just hurt.”

But I learned that this wasn’t so, and in many ways was part of the problem. I learned that I could drop the rope with the struggle and open up to anxiety just as it is without getting caught up in all the drama.  For the first time I saw that I wasn’t broken. There was nothing that needed to be fixed. What needed to change was my relationship with my old history, my mind and emotional life, and myself.”

So, instead of warfare I started practicing meeting my anxious mind and body more mindfully and with a heavy dose of kindness and compassion. I saw that I didn’t have to listen to everything my anxious mind was telling me. Most of the negative stuff around anxiety was unhelpful anyway. So, I practiced noticing thoughts, feelings, and sensations just as they are, like I notice so many other things around me in my life. This created space for me to focus on doing what I really wanted to do; the things in life that truly matter to me, like connecting with my family, loving my kids, my interest in sports, walking my dog, and building my career. Now I’m not saying that I like the old anxiety when it shows up. But the thing is I no longer allow it to run my life. I have found a place to carry it and do what I care about.” 

The client pauses for a moment, with a few tears in her eyes, and you offer an encouraging nod for her to continue. 

“So, to answer your question, I’m here because I would like therapists like you to hear that someone like me can live well with anxiety. I am a testament to that. Anxiety is not the enemy unless we give it that power. It doesn’t need to be reduced or removed to have a life. A good one, too. That workbook, that little blue workbook, taught me how to cultivate the conditions for my own happiness, something I never thought was possible with anxiety. And that changed everything. Everything! The tears I feel now are ones of joy because I got my life back. But I didn’t do it by going after the anxiety and fear to make it go away. I got it back by learning to let go, embrace what life offers, and pour my energies into what I really want to do, anxious or not. For the first time in my life I feel free. I just wanted someone like you to hear that. And hear that it’s possible to have a meaningful life with anxiety and fear. Thank you for listening.”

This scenario is unlike many clinical encounters precisely because we don’t see many people coming into therapy telling us about how wonderful their lives are, even with significant sources of psychological and emotional pain. But this is precisely what the workbook offers: An evidence-based approach to psychological health and wellness that dignifies the challenges of the human condition. 

As therapists, the workbook redirects the focus away from anxiety management and control and toward the skills needed to create the conditions for genuine happiness, anxiety or not. We learn to refocus our efforts on helping our clients discover (or rediscover) what matters to them and then skills to transform their relationship with all forms of anxiety and fear in the service of doing what they truly care about. 

Paradoxically, this is radical change. No other workbook for anxiety that we know of offers this kind of evidence-supported approach. And, our own research testing this workbook shows that people do find relief from all forms of anxiety and fear when they see that the door to their anxiety cage has been open all along. Our clinical role becomes one of empowering our clients to step and step again through the open door to create the kind of life they so desperately want to live.

NH: Tell us a bit about your background (personally and/or professionally) and why you feel you've been drawn to do this work.

JF: From a very young age, I learned that life is suffering.  That’s my Catholic upbringing speaking. There was no distinction between pain and suffering. One should simply carry their crosses. But how does one do that? For years, I simply did not know.  Most of the time, it was simply to gut it out and pray when life was hard.

Flash forward about 27 years. I did my formal graduate work at West Virginia University, where I was trained in traditional cognitive-behavior therapy with a heavy dose of applied behavior analysis. Traditional CBT was liberating for me because within the model was a set of evidence-based concepts and strategies to alleviate human suffering. I learned that there was a way to carry my cross. In fact, I learned there was a way to lessen its load and even drop the cross altogether by changing my thoughts and feelings. I also learned how to help others do the same. At the time, this seemed liberating. Humans could be happy and thrive if we could simply reduce, better manage, or correct unpleasant and unrealistic thoughts and painful emotions.

But as I learned cognitive and behavioral interventions I was also in tune with emerging work in applied behavior analysis. This work, coming out of a behavior analysis of language and cognition, suggested that there was a way forward with the pain we all carry, and even a distinction between pain and suffering. It even went further to suggest that one need not change what one thinks and feels to be happy and thrive. After all, we are all historical creatures. Our nervous systems are additive, not subtractive. If that is so, then how does one reduce or eliminate a thought or feeling? Isn’t this more struggle?  More suffering? More time and effort away from doing what matters?

Eventually this line of work, coming out of a single chapter titled Comprehensive Distancing” radically altered the way I view my own pain and suffering and those of the people I serve. Comprehensive distancing is what many now know as Acceptance and Commitment Therapy (or ACT, said as one word). So, I began to dance between two worlds—traditional CBT, and ACT. Within ACT, I learned that there is a distinction between pain and suffering.  As human beings we all carry our pain, but suffering is different. 

ACT outlined an entirely new model of psychological health and wellness, one where pain is not the enemy. Within ACT, a good deal of human suffering was exposed as a natural by-product of language and cognition, leading us to struggle unnecessarily with unpleasant aspects of our psychological and emotional experiences.  In short, ACT suggested we could learn to carry pain forward in directions that matter and without having to change what one necessarily thinks, feels, or remembers. This was and is old idea, but one that has now made its way into evidence-based psychology. 

ACT, as an approach, deeply resonated with my experience as a human being and offered a philosophy, a model of suffering and its alleviation, and a powerful set of intervention technologies to promote psychological health and wellness. ACT also drew me in for another reason. There is nothing in the model that says one must change thoughts and feelings to live a whole and dignified life. Instead, we learn to alter our relationship with what we already carry as historical beings and learn how to carry our own painful crosses forward with greater kindness and compassion in the service of creating a life worthy of our time. This message, supported now by hundreds of studies, is both radical and liberating.

Most of my professional work as a psychologist, professor, writer, ACT trainer, speaker, and consultant falls within the scope of ACT and more broadly an organization known as the Association for Contextual Behavioral Science. I am deeply invested in promoting psychological health and wellness and a good deal of my work these days is focused on sharing, with the public and professionals, ACT and mindfulness-based knowledge and skills so as to alleviate human suffering while cultivating psychological health, wellness, and human thriving. I do my best to maintain a regular meditation and yoga practice with my wife and together we also do our best to bring ACT sensibilities into our relationship. 

I also continue to enjoy travelling, the outdoors, playing guitar, and good wine with my lovely wife who also regularly co-leads ACT workshops for professionals with me.

I still have my crosses, but they have been made much lighter because of ACT. And for that, I am forever grateful.

NH: You and [co-author] Georg Eifert, PhD believed in the workbook so much that you conducted a research study to test it. This seems to reflect of an attitude inside the ACBS community that data is always our friend. Can you talk a bit about your thinking process behind wanting to test the book? Did you have any fear or anxiety about finding out that it didn’t really work?

Georg and I wrote the workbook with an abiding intention to help those suffering from any form of anxiety problem. But, as we know, good intentions do not always translate into good outcomes. So, even though the workbook was written with good intentions and guided by other research supporting Acceptance and Commitment Therapy (or ACT), we wanted to see if the workbook was, in fact, helpful when people used it on their own. Because we are both trained clinical scientists and psychologists, we thought we had a unique opportunity to put the workbook to the test.

This was risky, for sure. Very few self-help books have been tested in a rigorous way to see if they work when readers use them on their own. And, there were times when I got stuck thinking thoughts like,what if the workbook doesn’t help after all?  All that work, for nothing!” But we felt that doing a study to test the workbook was the right thing to do.  We also thought that we would learn something of value in the process, however the results turned out.

So, we assembled a team to evaluate the workbook using rigorous methods balanced with practical considerations. We didn’t want this study to be artificial with lots of rigorous screens and rule outs. We simply wanted to find out (a) is the workbook helpful, when used alone, by readers with significant problems with anxiety and depression and (b) in what ways, if at all, is the workbook helpful.

This was a leap of faith.  But all research is like that. We simply won’t know what works unless we bother to find out. We were curious enough and willing to risk finding out we were wrong and where we might be doing some good too. That was the spirit behind the workbook study. 

NH: What were some of the significant findings? 

JF: The focus of this study was to see if this workbook is, in fact, helpful and in what ways. So, we designed a study to see if the workbook makes a difference in the lives of people significant anxiety-related concerns (Ritzert, Forsyth, Berghoff, Boswell, & Eifert, in press).

We recruited an international sample of 503 people who reported struggling with severe anxiety and depression. Our research team then randomly assigned them, by flip of a coin, to either begin using the workbook right away for a period of twelve weeks, or to be on a wait-list for twelve weeks. After the twelve weeks, we offered the workbook to those who were initially on the wait-list, who then used the workbook for a period of twelve weeks too. We then followed everyone to see how they were doing six and nine months later.

You should also know that we had no contact with any readers in the study, so there was no coaching or therapist guidance. No big grant dollars either.  We funded this study out-of-pocket. All we asked was that participants read and work with the material in the workbook on their own. That’s it!

The workbook teaches many skills to help foster a different kind of relationship with anxiety and fear. These skills include being less avoidant and less tangled up with difficult thoughts, and more present, flexible, compassionate, kind with yourself, and accepting of your internal experiences just as they are. In this study, we measured these facets of peace and genuine happiness at the beginning of the study, after twelve weeks, and six and nine months later.

The good news is the results strongly support the benefits we mention throughout the workbook. Readers who used the workbook reported significant and meaningful improvements in mindfulness, self-compassion, and the ability to detach from unpleasant thoughts; they also became less avoidant and more accepting of anxiety, fear, and other unpleasant emotions. These changes coincided with using the workbook. Those on the wait-list showed these benefits once they started working with the workbook, but not before. Most importantly, readers maintained their improvements at the six- and nine-month check in.

So, the bottom line here is one of justified hope. The results show that the workbook radically changes the relationship people have with their anxious minds and bodies. Moreover, the results also show that—in line with its strong focus on values and doing what matters—the workbook improves the quality of people’s lives.

The workbook itself doesn’t emphasize anxiety and fear reduction. Still, we did look at what happened to the anxiety and fear in this large study of people from all over the world. What we found will be good news for those stuggling with anxiety and fear.

Readers who worked with the workbook reported significant reductions in their anxiety, fear, worry, and depression. You may wonder how that might be. How could a book that doesn’t focus explicitly on anxiety reduction end up decreasing anxiety, fear, and worry as well as depression?

To get the answer, we reanalyzed the data using sophisticated statistical analysis (called multiple mediation, in case you're interested).

Using mediation analyses, we looked to see if the skills we emphasize in the workbook have anything to do with the reductions we found in anxiety and depression and the improvements in quality of life. It turns out that they do (Sheppard & Forsyth, 2009).

In fact, when readers focused on learning the skills and cultivating a kinder and gentler relationship with their anxious mind and body, they reported feeling better. It was the skills that lead to anxiety lessening, depression lifting, and quality of life improving. It didn’t work the other way around. Reductions in anxiety and fear did not happen by going after anxiety and fear directly. It was just the opposite. Let this sink in, and linger with it a bit.

By first focusing on the skills needed to live a more valued life, readers then experienced a decline in their anxiety, fears, and depression, and ultimate improvements in their lives. This is an important message––one that supports the approach we offer in this workbook.

We took a risk in evaluating this workbook, and it paid off. In truth, we would have been fine if the results didn’t turn out as they did. But, across the board, the results show that the workbook works well and works in many ways.

But it only works for those who actually work with it. Readers in our study spent an average of four hours per week working with the exercises and material in the workbook, and most reported that it significantly changed their lives.

NH: What, if anything, do your findings from the study of this book suggest about bibliotherapy, as both a standalone and complement to traditional psychotherapy and/or pharmacotherapy for anxiety? Other mental health issues? 

JF: Bibliotherapies have been around for some time.  Many of them are evidence-supported, and many are not. Our study adds to this body of work in showing that self-help is helpful, even with people who struggle with significant anxiety and depression.  This is important, particularly knowing that many people do not have access to quality and affordable mental health care. It is also important in that our study showed that ACT, a transdiagnostic approach to psychological health and wellness, works without the guidance of a trained therapist. But this is where things get dicey.

Our findings do not mean that we don’t need therapists. I would never go that far. But this work does suggest that a workbook may be useful as a powerful adjunct to therapy. Though anecdotal, I know of several therapists who are using the Mindfulness & Acceptance Workbook for Anxiety in their clinical work with anxious clients. They have told me that the workbook adds a depth and richness to their clinical work, especially when applying ACT in the context of anxiety-related concerns. Some assign material in the workbook as between session reading, to reinforce concepts and to encourage skill development.

Outside of session work is critical for a number of reasons.  When you consider time spent in therapy relative to time spent outside therapy, there is an obvious gap. All therapists wish for their clients to make changes in their daily lives.  Therapy is a viable way to foster that. And yet, the client is ultimately left alone to do the bulk of that work in their daily lives. It is here where a workbook such as ours can make a difference by offering the client something concrete to guide them between therapy sessions in their efforts to make significant changes in their lives. In fact, the real work between sessions, where clients are trying to change their lives, looks very much like self-help. And, in some ways it is just that.

With ACT, it is often easy to miss that the skills and approach is broadly applicable to many areas of life where psychological and emotional pain seem to stand as barriers to doing what matters. Therapists often need to make explicit how skills outlined in the workbook can be helpful beyond anxiety barriers, such as with anger, sadness, disappointment, or loss. This will help greatly with other mental health concerns that anxious clients often present with.

There are exceptions too. For instance, in our workbook study, readers showed significant reductions in depression. This surprised us given that the workbook does not address depression. Yet, the findings suggest that the skills taught in the workbook for anxiety may also undermine the same set of processes that feed suffering linked with depression, hence the reason why anxiety and depression improved at post treatment and follow up.     

Whether the workbook works as an adjunct to pharmacotherapy remains to be seen. Yet, I see no reason why a workbook could not be combined with pharmacotherapy as a way to teach skills that clients may learn to use when navigating psychological, emotional, and behavioral challenges. 

NH: There’s a second study as well, right? Can you say anything about that? Any data available?

JF: We did do a second study comparing the Mindfulness & Acceptance Workbook for Anxiety with Bill KnausCognitive Behavioral Workbook for Anxiety. This study was smaller scale than the first, using a simple pre-post treatment design, with similar sample characteristics as the first study. Unlike the first study, the sample included only 61 individuals who reported significant anxiety-related difficulties.

Though preliminary, the results showed that both workbooks produced similar pre- to post-treatment changes in anxiety, worry, tendency to suppress thoughts, and sense of perceived control over anxiety. Yet, the Mindfulness & Acceptance Workbook for Anxiety yielded greater improvements in depression, anxiety sensitivity, and OCD and PTSD symptoms from pre to post-treatment relative to the CBT workbook. The Mindfulness & Acceptance Workbook for Anxiety also produced greater gains in mindfulness, cognitive defusion, metacognitions, self-compassion, psychological flexibility, and quality of life at post-treatment vs. the CBT workbook. 

Though preliminary, these findings suggest both ACT and CBT workbooks for anxiety improve anxiety and a sense of perceived control over anxiety.  Yet, the Mindfulness & Acceptance Workbook for Anxiety also appears to confer several additional benefits. And, like the first workbook study, it appears to move several core intervention processes within the ACT model that are linked to good clinical outcomes (e.g., mindfulness, psychological flexibility, defusion). 

NH: Lastly, tell us what’s new in the second edition that’s not in the first. 

JF: The second edition was entirely revamped to include guided mindfulness exercises throughout, and two new chapters; one address painful past memories and trauma and the other dealing with cultivating an observer self perspective (or, in ACT lingo, self-as-context perspective). We’ve also revamped the writing, examples, streamlined and enhanced the section of values, added new exercises, and retooled some tried and true exercises as well. The workbook also includes a new and expanded set of downloadable, guided meditation exercises. In the process of making the revisions, we were repeatedly facing the challenge of editing and updating while retaining the heart of the approach that we know works. We hope that we struck the right cord with the 2nd edition.

Many people dislike workbooks because the very name sounds like work. But this workbook is different. It is really a guidebook to psychological health and wellness and a roadmap into a more vital life. Living well is a challenge faced by just about everyone. If it were easy, then we’d all be doing it. But life can be hard and that can keep anyone stuck and far from the life they wish to lead.

My point here is twofold.  First, consider looking at this workbook not as work, but as being about something much bigger than that, particularly with your clients. Make it be about something bigger than anxiety and fear. Make it be about the kind of life your clients wish to lead; the kind of person they want to be about and become. 

Many self-help books have a one and done feel to them as you read along. New concepts and ideas are introduced and then largely forgotten. Readers like them for this reason.  After all, they’re always something new around the corner. But this is not how therapy normally progresses. It is also not how life progresses either.

If you look at therapy itself, there is an ebb and flow to it. New materials is not introduced and forgotten. It is woven into the fabric of therapy itself as therapy progresses. Skills are built upon. Old themes often return. Skills, concepts, even metaphors are reintroduced and used in new and sometimes unfamiliar ways. 

As we wrote the Mindfulness & Acceptance Workbook for Anxiety, we wanted to make explicit the continuity of the learning and are very explicit that there is some deliberate repetition within the workbook so as to reinforce key concepts and help the reader to learn how to apply skills in new ways. But your clients and some readers will judge this to be repetitive or boring. Here, it is important to notice that; this tendency to tune out and shut down and explore as a barrier to the client going forward in new and potentially more vital ways. If they are willing to move past those judgments and work with the material and you as a therapist, then they will likely learn something that will benefit them now and in the years to come.

For more, check out the Mindfulness & Acceptance Workbook for Anxiety.