The following case study is connected to the questions below: Please assist with answering the following questions in a synopsis format related to case study:

What were the earliest risk factors displayed for Ashley to develop somatic symptom disorder?

What role might the family and her family history have played in the development of her health-related worries?

In which ways did the COVID-19 pandemic impact Ashley's life?

How did Ashley change psychologically in response to the pandemic?

Do you think a different diagnosis, such as an anxiety disorder, was warranted? If so, could an anxiety disorder diagnosis have significantly impacted Dr. Husain's choice of treatment?

How do you think Ashley's anxiety impacted her GI problems, and vice versa?

Is Acceptance and Commitment Therapy a type of cognitive-behavioral therapy?

What were the targeted treatment mechanisms in Ashley's therapy? In other words, which of her psychological processes did Dr. Husain try to change in order to help her?

What does "acceptance" mean in this treatment?

What does "change" mean in this treatment?

What did Dr. Husain do at the end of therapy to reduce the risk for relapse in anxiety?

What tools and approaches were used to assess the efficacy of Ashley's treatment?

Case Study

Born into a family of doctors and nurses outside New York City on Long Island, Ashley was privileged in many ways. She was physically healthy, developmentally advanced, well-nourished with healthy foods, and had a large home protected with security cameras within a gated community. Her parents, both physicians, were disciplined hard workers earning high incomes. Their annual salaries combined, well into the seven figures range, afforded many luxuries and opportunities for Ashley and her younger sister Allie. Both girls were raised in private schools, had academic tutors, and received additional coaching and help from their live-in nanny, Carissa. The sisters were both highly intelligent and academically industrious. Driven by their parents to have multiple talents, they pursued modeling and acting gigs in addition to their studies. Between being tutored in Spanish and Carissa's directive from their parents to speak exclusively in Spanish to the girls, they became conversationally bilingual. Indeed, Ashley and her sister were born into a swift current of success in which they would never have to swim upstream.

Although the precise prevalence of somatic symptom disorder has not been determined, research has found that it may begin at any age and is more common among women than men (Levenson, 2020).

Ashley's mother, Sarah, was a cardiologist physician-scientist who had been a successful investigator and ran a large research team for many years before becoming a full-time clinician. Now she was a senior physician in the heart center at the hospital. She mostly performed costly and complicated procedures and met with patients for pre-operative and follow-up appointments. Sarah's deceased mother had been a nurse in a pediatric intensive care unit in Manhattan. Sarah's father was a pulmonologist who died following complications from an infection he received while on a mission to provide care to remote villages in the mountains of Ecuador. All of Ashley's grandparents had immigrated to the United States from northern Europe and, as Ashley and Allie heard repeatedly from their mother growing up, Sarah's ancestry had a long lineage of people with professions in the medical field. With such a history and physician parents who would best be characterized as determined and intense, it was inevitable that Ashley and her sister would grow up thinking that they too might become doctors. Ashley joked that understanding the human body was "in her DNA," and that it was her "destiny" to follow in the footsteps of her parents and grandparents.

Ashley's father, Jerry, was an orthopedic surgeon in private practice. He was a tall muscular man who had played football in college as an offensive lineman. Jerry's parents were both doctors, but they were family medicine doctors and Jerry always knew he wanted to be a specialist. He knew how much money the primary care doctors made, and he figured if he was going to medical school, he would be sure to choose a residency program and medical specialty that would bring him a very high salary. He was a serious man, focused on his patients and his practice, and worked over 70 hours most weeks. Both Sarah and Jerry were in good health. They would wake up at 4:30 a.m. and exercise or meditate most days before eating a low-fat high-protein breakfast and arriving at work by 7 a.m. Their daughters would awake most mornings to find their parents were already out the door. Carissa, an ebullient young Columbian nanny from Miami, would get them ready for school and be there to greet them when they came home.

Ashley not only excelled in school, she was the class salutatorian her senior year. She was accepted to several Ivy League schools, but was rejected from Harvard, Yale, and Princeton. It didn't matter much to her, because she had always wanted to go to a smaller college. She decided to attend a very small liberal arts school in upstate New York known for being a women's college. By the time she was a senior in high school, Ashley had traveled throughout the world and seen many different cultures. She had grown an appreciation for how different things were in America, and she was beginning to question her long assumed dream of becoming a neurosurgeon. Ashley: COVID-19 Totally Shifts Her World

In the spring of Ashley's senior year in high school, the world was hit by the COVID-19 pandemic. Everything changed. Ashley and her sister stayed home and shifted to remote schooling. They stopped seeing their friends in person. Ashley had an acting job that was cancelled, and all prospects of modeling were postponed indefinitely. Carissa, already highly attuned to the needs of the girls and the house, became obsessive about her health and the health of the family. She rarely left the house, and when she did it was only to go to the store to buy food and other essential items that could not be delivered. Carissa became, in Ashley's mind, extremely anxious and over-protective. All they talked about was COVID the deaths, the infections, the transmission locally, nationally, and internationally, how to prevent it, what was known, what was unknown, and so on. It was all exhausting to Ashley, but there was no way to avoid it. COVID-19 had totally shifted her world.

As many as 60% of people confined to their homes during epidemics report substantial feelings of loneliness and sadness (Brooks et al., 2020; Ornell et al., 2020).

Sarah and Jerry were thrust onto the front lines managing patients with COVID. They worked long days and came home well into the evening most nights, their faces long with sadness and indented with red marks from hours in tightly outfitted personal protective equipment. Sarah took the brunt of it, as she had been redeployed by her department leadership to work the emergency room and intensive care unit. She listened to countless last words spoken wearily before intubation, ventilation, and, all too often, inexorable defeat to the aggressive virus. As time went on, she became increasingly despondent and helpless about the task of saving her patients and bearing witness to their lives ending without the dignity and comfort of loved ones nearby. At first, she kept this from Ashley, but eventually she decided that because Ashley wanted to become a doctor and would soon be away at college, it was time to be more open about her experiences. They started to have late night talks in the kitchen. Sarah shared with Ashley how ineffectual she believed she had become. She also disclosed how she had never felt so burned out from work. Always a woman who had been indefatigable and unflappable, she had become emotionally depleted by the daily deaths and angered by the lack of resources and endless bureaucratic processes in her hospital. One day, after noticing that she felt nothing but numbness when holding up a tablet to a patient to say goodbye to their children before being intubated, Sarah came home and broke down emotionally. She, Jerry, and Ashley talked about it in the kitchen for hours that night. Ashley held back her own tears but was upset to see her mother so badly affected. She suggested Sarah talk to a psychologist or psychiatrist. Jerry, never one to show his emotions, listened and tried to provide solutions. In a way, COVID was bringing Ashley closer to her parents. This was important to her. Seeing her mom with her hair down, transparently showing her emotions, Ashley felt especially connected to her. Allie, on the other hand, was in the basement FaceTiming her friends from the theater room, oblivious to it all.

According to worldwide surveys conducted just one month after the COVID-19 pandemic began, 73% of health care personnel had developed ongoing feelings of severe stress (N. Liu et al., 2020; S. Liu et al., 2020; Wang et al., 2020).

As the pandemic escalated into the summer, Jerry remained stereotypically masculine and stoic. "Toxic masculinity," Ashley would sometimes call it. Jerry would respond by calling her "a woke Gen-Z'er." Jerry's patient care had changed due to COVID. It shifted from elective procedures and routine visits to required and complicated surgeries. His team of nurses and technicians, usually consistent and reliable, frequently missed work due to illness or child care needs. Medical errors in his practice increased. Patient satisfaction decreased. The quality of care was eroding, and revenue was rapidly diminishing. Jerry was highly anxious about it all, but erroneously believed that trying to escape from or avoid his worries and inhibit his emotions would be the best way to cope. The whole family knew this was his go-to coping strategy. It was an open joke. Ashley and Allie, unsurprisingly, had picked up on this habit during their early adolescence. They had become experts at changing topics, deftly avoiding doing things that were unpleasant, or showing strong negative emotions.

Things at Jerry's work went from bad to worse when Ashley's favorite nurse, Consuela, contracted COVID and became seriously ill after attending an indoor family event for her aging mother. Jerry explained to Ashley that Consuela was put into a medically induced coma, and that she may or may not survive. The next day, Ashley learned that her best friend's uncle had died from COVID. Until then, as heartbreaking and devastating as it all was, death from the pandemic had not directly impacted Ashley. Now her best friend was dealing with a loss caused by COVID, and Consuela could be next. Ashley's world was turning upside down.

As the fall semester approached, Ashley chose to stay home with her family rather than live far away in a dorm, sequestered and, at some point, likely to be quarantined in a chain hotel rented by the school to prevent the transmission of the virus. She had become anxious about anyone in the family contracting COVID. This was especially true for her parents, who continued to put themselves in harm's way to take care of others. Consuela was taken off the ventilator and died, alone, in a hospital outside of her hometown and away from her family. It deeply affected Ashley, causing her to isolate herself even further. Carissa's parents in Miami had both contracted COVID, and Ashley knew many friends whose family members had been directly affected by the pandemic. Allie, a junior in high school, was becoming more and more distant from the family and alarmingly nonchalant about becoming sick with the virus.

Several months into the COVID-19 pandemic, 30% or more of surveyed people had developed moderate to severe symptoms of general anxiety symptoms that extended well beyond the specific health, economic, and family fears triggered directly by the spread of the virus (Cenat et al., 2021; Fountoulakis et al., 2021; Wang et al., 2020).

Once Ashley and her family were vaccinated, she became a bit less worried. Things started to look more hopeful. Her parents were less stressed and went back to their regular work routines. The family took a summer trip to Alaska. She and Allie spent more time out together doing the fun things they used to do. Still, after being away from her friends for so long, Ashley felt ambivalent about her friend group. She continued to politely avoid getting together in person, and instead spent more and more time online. Through her acting and modeling, she had a decent sized Instagram following, and she enjoyed interacting with people through direct messages, even from people she didn't know personally. In fact, she was able to connect with several people who had friends going to her college. As a result, Ashley became friendly with them, and enjoyed talking and texting with them in anticipation for the coming school year.

Ashley's parents had raised her to be open-minded and accepting of others. She was non-judgmental about other people's race, ethnicity, sexuality, and gender identity, for example. However, her childhood friends all seemed to be cisgender and heterosexual, and she had grown up in an upper-middle-class community that was predominantly white. She was excited about the prospect of meeting people from a lot of different backgrounds at college, as she always felt both privileged and, at the same time, trapped by her suburban upbringing. "We live in a bubble," Carissa used to say when they were younger. Ashley wanted to see what life outside the bubble was like. Allie, on the other hand, seemed to thrive inside her bubble. She was extroverted, confident, and fun, with a bubbly personality. She knew everyone in town, it seemed, and she thrived in this environment. As Ashley was preparing to go away to college, she sensed a coming sadness about losing Allie. She was missing her before she even left. "Pre-miss," Carissa called it, something a therapist told her years ago when she was leaving her family behind in Miami to become a full-time nanny.

At college, Ashley met many new people. She was friendly and attractive, and dressed down in order to not come across as intimidating or full of herself. She knew if she dressed up, she would get a lot of attention from men and, as she would learn, from plenty of women. And she didn't really want it now that she was so nervous about strangers and was away from acting and modeling, away from her bubble. She wore a mask everywhere, even inside when alone in her dorm room. Without a mask, she felt vulnerable, as though her safety could be easily compromised.

Through it all, she loved the atmosphere at college. Everyone came from different and unique places. They all were smart and studious, and having recently jettisoned some of the constraints and fears of COVID-19, the students she met all seemed fun, curious, and ready to cultivate new relationships. Ashley went to parties, drank more alcohol than she ever had in high school, tried cannabis gummies, and smoked marijuana. She made new friends, hooked up with a cute guy from her Bio class, and found herself endlessly receiving attention.

Despite all the excitement, Ashley was still feeling the effects of COVID psychologically. Her general level of anxiety was higher than it was before the pandemic. She had become more anxious about becoming sick, anxious about contracting COVID-19, anxious about her family and friends becoming ill, anxious about people she didn't know carrying the virus, anxious about so many things that all connected back to COVID-19. Most of the students rarely wore masks, but she refused to take hers off unless she was drinking or using drugs. To help with her anxiety, Carissa reminded her to do yoga, meditate, and exercise regularly. Her parents told her to eat well and stick to a routine. Allie told her she was overreacting to everything.

Ashley tried everything to help get rid of her anxiety yet still felt daily surges of agitation, jitters, and dread. Her worries about being infected meant that she would wipe down surfaces in the classroom, clean her hands throughout the day, and avoid people she didn't know. She had made close friends quickly, and she felt safest around them. But when they went out together, she felt a spike of overwhelming anxiety about becoming infected. To cope with this, she avoided new situations as much as possible. When she went out to new places or with new people, she would eat a cannabis gummy and drink a lot of alcohol to keep her worries at bay. This worked in the short-term and it became a new pattern for her.

Surveys conducted during the COVID-19 pandemic found increases in the number of children and adolescents who generally felt edgy (54%), annoyed (47%), worried (47%), sad (44%), and apathetic (54%) (Gindt et al., 2021; Zhou et al., 2020).

One night while Ashley was with friends at an off-campus party, she was hit on by a classmate, introduced as Rachel, who she recognized from the nearby dorm. They had never talked before, but Ashley had admired Rachel's bold sense of style from a distance Rachel rocked a short haircut dyed bright blue, a nose ring, flowery tattoos, and colorful makeup, plus a fashion sense Ashley thought of as tomboyish. They talked for hours; high and disinhibited, Ashley was surprised to find herself not only flirting, but also opening up about all of her secret anxieties. In turn, Rachel felt comfortable enough to open up to Ashley about identifying as nonbinary and queer and using "they/them" pronouns. Rachel had a confident, almost gruff manner, but got nervous around Ashley and stumbled over words. Likewise, Ashley found herself totally enraptured. They kissed at the end of the night, sloppy but passionate, Ashley's guard lowered by the alcohol and cannabis in her system. Normally, such close contact would have triggered her anxieties about COVID, but even the next morning, all Ashley could think about was Rachel and how she wanted to see them again.

What was going on? Ashley had gone away to college and was becoming a new person. The new Ashley was even more anxious, regularly using drugs and alcohol, and, now she was making out with someone she never would have expected herself to be attracted to. And she couldn't stop thinking of Rachel. Ashley began questioning her sexuality. She had identified as cisgender and heterosexual, and had her first sexual experience with a boyfriend in high school. As a model, she had spent a lot of time around attractive women and girls since she was a child. She never had noticed any sexual interest in women before, though she admired and always found herself paying attention to good-looking women. As she thought about it, she realized that she had always found women with shorter hair attractive. She loved to look at them on the runway when modeling, and had tried unsuccessfully to befriend several similar looking models in the past.

Dating back to the bubonic plague in medieval Europe, studies have found increases in the prevalence of anxiety, depressive, and substance use disorders in communities and nations overrun by epidemics (Ren, Gao, & Chen, 2020; Usher, Durkin, & Bhullar, 2020).

Ashley and Rachel became close as the months went on, frequently hooking up in private, and always flirting heavily when out in public. Ashley wondered what it meant for her identity that she was dating a nonbinary person. Was she bisexual, or pansexual maybe? She wasn't sure, but she knew she felt good with Rachel. More important, she felt safe when they were together. Rachel seemed to have a balanced blend of healthy masculinity and femininity. And Ashley felt comfortable being public about their growing relationship. Her parents were supportive. So was Carissa. When she told Allie, her sister replied dismissively in an invalidating manner. Although they had become distanced from each other since the pandemic, the sisters were still close. They had been tightly bonded as children, and with so much time together, it would take a catastrophic event to pull them apart. During the spring semester of her sophomore year, Ashley received a phone call from her mother that she had been dreading. Allie had become sick, contracting a mutated variant of COVID-19 that the vaccine was less than 100% effective against. She was in the hospital where Sarah worked and in serious condition. Ashley came home from school immediately and went to see her sister. Allie was sleeping, pale white and highly medicated, while rhythmic beeping sounds and vibrations from the bed and calf massager interrupted the silence every so often. Ashley was terrified and sat silently crying. Who was she becoming? How had her life, once so predictable, now careened off course? She looked at herself in the mirror. She looked different than before college. Her hair was up; she wore no makeup and a baggy school hoodie with loose leggings. She had a new nose ring.

On average, the bodies of elderly persons have slower-acting immune systems than younger persons, putting older adults at a greater disadvantage when trying to overcome influenza, pneumonia, viral infections such as COVID-19, and other serious medical illnesses (Bajaj et al., 2021; Begley, 2020).

Ashley had many previous nightmares about Allie or her family members getting sick and dying. She had worried at night, worried during class, worried all the time about her family becoming ill. Now Allie's lungs were infected, and she was having trouble breathing. What if she never fully recovered and had lifetime difficulties breathing? Or worse, what if she were to die?

Thankfully, Allie was eventually discharged in good condition, and Ashley went back to school to finish the semester. She was rattled. Her anxiety about becoming sick increased. She reacted to every physical discomfort she had as though it could be a crisis. Pains, aches, coughing, sneezing, anything all of it was met with scrutiny and paralyzing uncertainty. This led to a marked increase in her going to the campus health center. It also led to an increase in her cannabis and alcohol use. She became more difficult to be around socially. Rachel, who once couldn't get enough of Ashley, was now keeping some distance from her, only hanging out when partying, when it was likely that Ashley would be easier to be around and less intense.

Since the start of the COVID-19 pandemic, alcohol and drug use, the number of persons displaying alcohol and drug use disorders, and the number of fatal drug overdoses have risen significantly (Niles et al., 2021; CDC, 2020a; Valinsky, 2020).

The worst part of it seemed to be the onset of new GI problems. Ashley's stomach aches started soon after she arrived on campus, and worsened over time. She went to the campus health center several times to be evaluated, but they were unable to discern any organic cause each time. As a result, Ashley began a gastritis diet, avoiding red meat, acidic and spicy foods, and her favorite caffeine. She continued to drink alcohol but shied away from beer. Still, her stomach and intestines ached most days. After seeing a gastroenterologist and receiving an upper endoscopy, no acute medical problems were discovered. She was diagnosed with functional dyspepsia (indigestion resulting from a nonorganic source) and learned that she was at risk for irritable bowel syndrome or stomach ulcers in the future. This failed to quell her anxiety. Instead, she felt even more unpredictability and uncontrollability about her health. In a vicious cycle, this seemed to increase her anxiety and when she felt increased anxiety, she tended to feel greater pain. Her gastroenterologist explained that, generally speaking, the mind and body are tightly connected, with each influencing the other. When Ashley asked questions, the doctor further suggested that the mind is not distinct from the body. What we experience and call our "mind" is neurobiological, with complex processes occurring in the brain and body influencing how and what we think, feel, and sense in our body. Ashley left wondering, is my anxiety making my GI problems worse? Or are my GI problems making my anxiety worse? If there is nothing wrong with my GI system, why do I feel so much pain? She was overwhelmed and felt hopeless about what to do. Rachel told some of their mutual friends they were wanting some space from Ashley. "I loved spending time with her at the beginning. She was fun, cute as hell, and was into me. She accepted me for who I am. She never questioned anything. Sure, she was wound up tight. But who wasn't at that time? We were coming out of the lockdown phase of the pandemic and back to school, finally. It was a weird time for everyone. I was more uptight then too.

"But after her sister got sick and recovered from COVID, Ashley seemed changed for the worse. I tried to help comfort her, but it didn't seem to matter. Unless she was drinking or high, Ashley was kind of difficult to be around. All she talked about was her health and her worries about getting sick. It was like that was the only thing she was thinking about. I love being with her, but I just can't be around all that negativity and worry. It's like, come on girl, you got this. You have everything anyone could ever want. And all you can do is think about getting sick? I'll still be her friend, and when she's cool, I'll totally spend more time with her. Honestly, truly, she's got this ongoing mysterious thing going on with her stomach. It's not something simple, like lactose intolerance. And it's always on her mind. She needs help, you know, like from a doctor or therapist, or someone." shley's sophomore year spring semester grades were the lowest she had ever received: two B's and 2 A's. She was devastated. She got a B in Bio and a B- in Chem. Maybe it was from avoiding classes out of her worry she might make her GI pain worse. When she was in class, she had a hard time focusing on the lectures. Her mind raced, and she noticed every new sensation in her body. What would this mean about her chances of becoming a doctor? She had changed so much this year, and now she wondered about whether she should change her major and career ambitions. Sarah and Jerry saw how bedraggled and unsteady Ashley had become, and suggested she see a psychiatrist or therapist that summer. Ashley responded by saying she had no interest in taking medicine to deal with her worries, but that she would see a psychologist.

Sarah spoke with her colleagues in the Department of Psychiatry and came home with several recommended therapists. Ashley deeply respected her mother and decided to contact Dr. Zakir Husain, a clinical psychologist with expertise in health anxiety. She requested that they meet remotely using a telemental health approach. He agreed and they met several weeks later for an initial evaluation. After gathering biopsychosocial history information that is, asking about her medical history, personality and coping strategies, and relationships Dr. Husain asked a series of diagnostic questions related to anxiety, substance use, and health concerns. He learned that her anxiety began to be problematic during the height of the COVID-19 pandemic, and that the scope of her anxiety was limited to somatic concerns. Each day, she worried repeatedly about her health but was not particularly anxious about other parts of her life. He told her she likely met diagnostic criteria for somatic symptom disorder, but that he would need more information to confirm this diagnosis. He suggested she also appeared to meet criteria for a substance use disorder but believed the function of her substance use was primarily to reduce anxiety related to her overall health in general and to her GI symptoms more specifically. He wanted to target her health anxiety using an evidence-based form of cognitive-behavioral therapy called Acceptance and Commitment Therapy, or ACT for short. Ashley was saddened to hear his conclusions, but they made sense to her, and she was relieved there was a path forward. "Help is on the way," Dr. Husain said, smiling warmly, as they ended their first appointment together.

Although enthusiasm for telemental health services had been gaining some momentum for more than a decade, it was the COVID-19 pandemic and related social distancing that truly propelled such services into the clinical mainstream, due in part to expanded insurance coverage (APA, 2020b; Connolly et al., 2020; Wicklund, 2020).

The next week, they met for their second session, and the first one using ACT. Dr. Husain asked Ashley how willing she was to try this treatment, and she remarked that she had been both excited and nervous. "Ah, ambivalence," he noted. "Notice your mind having ambivalent thoughts." Ashley ignored him and started to talk about things that happened to her in the last week. She explained how she had been feeling sick, having GI pain, worrying about her health, and volunteering at her mother's hospital. She waited for him to say something, but when he did, she was surprised. Instead of asking her to share more details, instead of reflecting and paraphrasing what she had said, instead of encouraging her to talk more about her experiences or her anxiety, instead of doing all the things she had seen in the movies and TV shows that therapists do, Dr. Husain quickly acknowledged Ashley's emotional distress and then gently requested permission to ask her several questions.

For many years, somatic symptom disorder and related problems (conversion disorder and illness anxiety disorder) were referred to as hysterical disorders, a label meant to convey the past belief that excessive and uncontrolled emotions underlie the bodily symptoms found in these disorders (Stone & Sharpe, 2020).

Dr. Husain: It's normal to talk about anxiety and all the things that cause us distress. I do it. Everyone I know does it. It's common, especially in Western cultures. But consider this: What if talking about our distress in and of itself was part of the problem? What if it is not the solution after all?

Ashley: I don't understand.

Dr. Husain: Maybe you do, but your mind tells you that you don't?

Ashley: My mind is me.

Dr. Husain: Is it? What is your mind?

Ashley: What do you mean?

Dr. Husain: Literally, if you take a step back from the content of your mind, what is it, exactly?

Ashley: I don't know. Maybe my mind is my ... thoughts?

Dr. Husain: If your mind is your thoughts, are you your thoughts?

Ashley: No. I am me. Bones, organs, blood, and all the rest of my body.

Dr. Husain: And your body creates sensations, like hunger, thirst, fatigue, and so on.

Ashley: I don't get it.

Dr. Husain: Your body produces sensations, and your brain, which is a part of your body, creates thoughts. Or at least a part of your brain does this. And other parts of your brain do other things, like helping you see, smell, hear, and so on, or keeping you breathing while you sleep, standing when you walk, and so on. Your brain has parts that enable you to think, and, at the same time, it also has the ability to observe that you are thinking, or to notice what you are thinking.

According to research, people with higher levels of somatic vigilance a general inclination to attend to one's body, and to worry about bodily arousal and discomforts are more likely than other people to experience pain and pain-related anxiety (Burton et al., 2020; D'Souza & Hooten, 2020a).

Dr. Husain went on to provide an orientation to ACT. He explained that unlike treatments designed to help by listening only, or treatments intended to help by changing what people think using techniques like cognitive reappraisal, ACT would help her in a different way. Ashley was intrigued. She thought she was supposed to talk about her problems in therapy, and that Dr. Husain, or any therapist for that matter, would listen, support, problem-solve, and help with advice on what she should do to reduce her anxiety. Dr. Husain differentiated ACT from other versions of cognitive-behavioral therapy (CBT) by saying that in ACT, the goal is not necessarily to get rid of anxiety or have fewer worries. He had no intention of asking her for evidence to support or possibly refute the truth of her worry thoughts. Inasmuch as ACT does target cognitive processes, it is considered a type of cognitive-behavioral therapy. But it is, as Dr. Husain described, an acceptance-based CBT. He would help her change her patterns of behavior by guiding her to mindfully and acceptingly observe the thoughts and feelings going through her head and body at any given time, and then teaching her to replace her habitual reactions to such thoughts and feelings with responses that were more useful and "value-based." That is, although Ashley might typically accept her thoughts as "true," he would help her learn to accept her thoughts as mere thoughts, not to be conflated with unquestionable truths. Instead of playing tug of war with the truth of her worrying thoughts, he would help her let go of the rope and focus more on her daily functioning, irrespective of the worries she might be having. He used a number of metaphors, including one about falling into a hole and trying to get out using a tool that only kept her stuck and digging deeper. The session ended, and Ashley's head was spinning.

Mindfulness techniques, which guide people to observe their thoughts and bodily sensations without judgment, were brought into the clinical mainstream by psychologist Steven Hayes and his colleagues as an important feature of their broader approach, Acceptance and Commitment Therapy. Because he was using ACT, Dr. Husain frequently relied on metaphors and experiential exercises instead of the more traditional back-and-forth conversational tools common to social dialogue. To help Ashley differentiate between her thoughts and her "self," he described her thoughts as "bullies on a bus," wherein she was the driver and her thoughts, like bullies, sat in the back of the bus yelling at her, threatening her with possible catastrophes and telling her what could happen if she did this or that behavior. The bullies, Dr. Husain suggested, were used to getting their way, essentially hijacking her life by telling her what to do. Although she could, in fact, have steered the bus of her life in any way she valued, she had been too busy believing the bullies, and acceding to their demands. As a result, she had taken too many lefts and rights away from the ways she valued living, listening to the bullies as though they knew the right way to go. Under Dr. Husain's guidance, Ashley started paying attention to these thoughts (the bullies on her bus), examining her interpretations and assumptions, and observing the ways the thoughts were directing her to live her life. She started to see a disturbing pattern: The bullies almost always convinced her to avoid people, places, or things that she wanted to approach things that were often important to her. The bullies on her bus had been convincing her to avoid all possible risks. Indeed, as she later told Dr. Husain, she was coming to appreciate that she had been held hostage by her own thoughts. She had become fused to her thoughts confusing thoughts with truths.

Albert Einstein once said, "We cannot solve our problems with the same thinking we used when we created them."

In another session, Dr. Husain tried to help her defuse from the meaning of her thoughts by having her say out loud, repeatedly with him, the word "milk." They said it together over and over: "milk, milk, milk, milk, milk, milk, milk, milk, milk, milk, milk, milk." Eventually, Ashley stopped and giggled, declaring, "The word loses its meaning when you say it so many times." This was the point, she learned. Then Dr. Husain asked her another one of his mind-numbing questions. "What if our thoughts are simply words, comprised of phonemes and arbitrary utterances made by our mouth and tongue? What if the meaning we take from our words is based on our unique learning history and the context in which we think, or talk?" Ashley was curious, and it was making sense. She stopped him, "Is this sort of like the bullies on the bus, where I can choose to make sense of and react to my thoughts however I want to? Like, I am not simply my thoughts but I can see them and choose whether to believe them or to let them go?" This time, Dr. Husain was the one doing the nodding.

As the summer wound down, they began moving toward the process of ending therapy. Dr. Husain called it "termination," then chuckled and said that he despised that word and would instead call it "ending therapy," for now. He had been consistently using self-report measures to assess Ashley's anxiety, valued actions, and tendency to try to avoid her internal experiences, or, as he called it, "experiential avoidance." On all measures she was improving significantly. Except one. She was still highly anxious, in the moderate range on a standard measure of anxiety symptoms. But her valued actions had increased, she was avoiding her anxiety less, and she was living more aligned with her values. Her GI pain had diminished only a bit, though she had learned to react without avoidance when she did experience any stomach pain. Sure, she wanted all the pain and discomfort to stop, and she continued to monitor and be sensitive to internal sensations throughout her GI tract. But it was all less impairing than it used to be.

As they moved session by session closer to the end of therapy, Ashley observed that she was noticing a lot of anxious thoughts about returning to school, about ending therapy, and, of course, about the possibility that she might become sick when she got back on campus. At the same time, she tearfully shared her insights about the useful things she had learned that summer. She had been drinking much less, rarely using cannabis, spending more time with the people who mattered most to her, and being the kind of person she valued as much as possible when with them. She made a point of spending time with Allie and her parents, appreciating Carissa more openly, and being with friends who enabled her to be her more authentic self. She also came to recognize and disclose that she was bisexual, sexually attracted to people across the entire gender spectrum. She would return to college looking for a partner with whom she could express her truest values honestly and vulnerably. Ashley noted that she had been learning to stay in contact with her thoughts and emotions, without trying to escape from them anymore. In turn, she had become more aware of the opportunities to be in the moment, increasingly defused from her thoughts even when feeling emotionally distressed, and no longer subject to the demands of the bullies on her bus. She had been psychologically imprisoned but now felt free; she joyfully told Dr. Husain that she had been "blind all the time but was learning to see." It was a lyric in a song she heard, and it rang true. "Psychological inflexibility," Dr. Husain said assuredly with a smile and subtly cocked head, "psychological flexibility."

In the final session, they reviewed her treatment progress, consolidating everything that had been learned. They planned for ways to generalize and maintain her new ways of relating to her internal experiences. They developed and wrote out a plan. In the event that her avoidance and psychological inflexibility returned, a "relapse" as he called it, she had a plan. She would complete a revised values clarification worksheet, identify where she was living most out of touch from her values, practice mindful awareness of the present moment, observe efforts to avoid or escape from her anxiety, keep reminders of what helped in her phone, and remember certain key phrases that evoked strong memories of metaphors with Dr. Husain. They scheduled follow-up video appointments each month, and she could cancel them if she wanted to. She would keep each one.