The ACT intervention consisted of three 2-hr group sessions scheduled during a single week. Sessions followed an intervention manual that was developed and tested in an initial open trial using an independent sample of patients (Luoma et al., 2008). The manual is available from the authors (or at www.contextualpsychology.org/treatment_protocols). Participants were told that the groups were intended to help them overcome shame, stigmatization, and judgments of self and other. Standard ACT exercises were modified to focus on how to respond to shame and self-stigmatizing thoughts in a way that would not obstruct recovery. The first session focused on the workability of suppression and avoidance, and a rationale for defusion and acceptance skills was built using well-known ACT exercises such as the polygraph metaphor and the bus metaphor (Hayes et al., 1999). The second session taught defusion and acceptance skills through such exercises as 30 s of word repetition focused on a negative self-judgment, a procedure known to reduce both fusion with thoughts and the distress they evoke (Masuda, Hayes, Sackett, & Twohig, 2004). The second session also included a mindfulness
