This sweet friends - is FANTASTIC!!!
By Russel Harris
Psychotherapy In Australia 2006
Imagine a therapy that makes no
attempt to reduce symptoms,
but gets symptom reduction as a byproduct.
A therapy firmly based in the
tradition of empirical science, yet has a
major emphasis on values, forgiveness,
acceptance, compassion, living in
the present moment, and accessing a
transcendent sense of self. A therapy
so hard to classify that it has been
described as an ‘existential humanistic
cognitive behavioural therapy’.
Acceptance and Commitment
Therapy, known as ‘ACT’ (pronounced
as the word ‘act’) is a mindfulness based
behavioural therapy that
challenges the ground rules of most
Western psychology. It utilizes an
eclectic mix of metaphor, paradox,
and mindfulness skills, along with a
wide range of experiential exercises
and values-guided behavioural
interventions. ACT has proven
effective with a diverse range of
clinical conditions; depression,
OCD, workplace stress, chronic
pain, the stress of terminal cancer,
anxiety, PTSD, anorexia, heroin
abuse, marijuana abuse, and even
schizophrenia. (Zettle & Raines, 1989;
Twohig, Hayes & Masuda, 2006;
Bond & Bunce, 2000; Dahl, Wilson
& Nilsson, 2004; Branstetter, Wilson,
Hildebrandt & Mutch, 2004). A study
by Bach & Hayes (2002) showed that
with only four hours of ACT, hospital
re-admission rates for schizophrenic
patients dropped by 50% over the next
six months.
The goal of ACT
The goal of ACT is to create a rich
and meaningful life, while accepting
the pain that inevitably goes with it.
‘ACT’ is a good abbreviation, because
this therapy is about taking effective
action guided by our deepest values
and in which we are fully present and
engaged. It is only through mindful
action that we can create a meaningful
life. Of course, as we attempt to create
such a life, we will encounter all sorts
of barriers, in the form of unpleasant
and unwanted ‘private experiences’
(thoughts, images, feelings, sensations,
urges, and memories). ACT teaches
mindfulness skills as an effective way
to handle these private experiences.
What is mindfulness?
When I discuss mindfulness with
clients, I define it as: ‘Consciously
bringing awareness to your here-and-now
experience with openness, interest and
receptiveness.’ There are many facets
to mindfulness, including living in
the present moment; engaging fully
in what you are doing rather than
‘getting lost’ in your thoughts; and
allowing your feelings to be as they
are, letting them come and go rather
than trying to control them. When
we observe our private experiences
with openness and receptiveness, even
the most painful thoughts, feelings,
sensations and memories can seem less
threatening or unbearable. In this way
mindfulness can help us to transform our relationship with painful thoughts
and feelings, in a way that reduces their
impact and influence over our life.
How does ACT differ from other
mindfulness-based approaches?
ACT is one of the so-called ‘third
wave’ of behavioural therapies—along
with Dialectical Behaviour Therapy
(DBT), Mindfulness-Based Cognitive
Therapy (MBCT) and Mindfulness Based
Stress Reduction (MBSR)—all
of which place a major emphasis on
the development of mindfulness skills.
Created in 1986 by Steve Hayes, ACT
was the first of these ‘third wave’
therapies, and currently has a large
body of empirical data to support its
effectiveness.
The ‘first wave’ of behavioural
therapies, in the fifties and sixties,
focused on overt behavioural change
and utilized techniques linked to
operant and classical conditioning
principles. The ‘second wave’ in
the seventies included cognitive
interventions as a key strategy.
Cognitive-behaviour therapy (CBT)
eventually came to dominate this
‘second wave’.
ACT differs from DBT, MBCT,
and MBSR in many ways. For a start,
MBSR and MBCT are essentially
manualised treatment protocols,
designed for use with groups for
treatment of stress and depression.
DBT is typically a combination of
group skills training and individual
therapy, designed primarily for group
treatment of Borderline Personality
Disorder. In contrast, ACT can be
used with individuals, couples and
groups, both as brief therapy or long
term therapy, in a wide range of
clinical populations. Furthermore,
rather than following a manualised
protocol, ACT allows the therapist
to create and individualise their own
mindfulness techniques, or even to cocreate
them with clients.
Another primary difference is
that ACT sees formal mindfulness
meditation as only one way of many to
teach mindfulness skills. Mindfulness
skills are ‘divided’ into four subsets:
acceptance;
cognitive defusion;
contact with the present moment;
the observing self.
The range of ACT interventions
to develop these skills is vast and
continues to grow ranging from
traditional meditations on the
breath through to cognitive defusion
techniques.
What is unique to ACT?
ACT is the only Western
psychotherapy developed in
conjunction with its own basic research
program into human language and
cognition—Relational Frame Theory
(RFT). It is beyond the scope of
this article to go into RFT in detail,
however, for more information see
www.contextualpsychology.org/rtf.
In stark contrast to most Western
psychotherapy, ACT does not have
symptom reduction as a goal. This is
based on the view that the ongoing
attempt to get rid of ‘symptoms’
actually creates a clinical disorder in
the first place. As soon as a private
experience is labeled a ‘symptom’, it
immediately sets up a struggle with it
because a ‘symptom’ is by definition
something ‘pathological’; something
we should try to get rid of. In ACT,
the aim is to transform our relationship
with our difficult thoughts and feelings, so that we no longer perceive
them as ‘symptoms’. Instead, we learn
to perceive them as harmless, even if
uncomfortable, transient psychological
events. Ironically, it is through this
process that ACT actually achieves
symptom reduction—but as a byproduct
and not the goal.
Another way in which ACT is
unique, is that it doesn’t rest on the
assumption of ‘healthy normality’.
Healthy normality
Western psychology is founded on
the assumption of healthy normality:
that by their nature, humans are
psychologically healthy, and given a
healthy environment, lifestyle, and
social context (with opportunities
for ‘self-actualisation’), humans will
naturally be happy and content.
From this perspective, psychological
suffering is seen as abnormal; a
disease or syndrome driven by unusual
pathological processes.
Why does ACT suspect this
assumption to be false? If we
examine the statistics we find that
in any year almost 30 percent of the
adult population will suffer from
a recognised psychiatric disorder
(Kessler et al, 1994). The World Health
Organization estimates that depression
is currently the fourth biggest, most
costly, and most debilitating disease in
the world, and by the year 2020 it will be the second biggest. In any week,
one-tenth of the adult population is
suffering from clinical depression, and
one in five people will suffer from it at
some point in their lifetime (Davies,
1997). Furthermore, one in four adults,
at some stage in their lifetime, will
suffer from drug or alcohol addiction.
There are now over twenty million
alcoholics in the United States alone
(Kessler et al, 1994).
More startling and sobering is the
finding that almost one in two people
will go through a stage in life when
they consider suicide seriously, and
will struggle with it for a period of two
weeks or more. Scarier still, one in ten
people at some point attempt to kill
themselves (Chiles and Strosahl, 1995).
In addition, consider the many
forms of psychological suffering that
do not constitute ‘clinical disorders’—
loneliness, boredom, alienation,
meaninglessness, low self-esteem,
existential angst, and pain associated
with issues such as racism, bullying,
sexism, domestic violence, and divorce.
Clearly, even though our standard
of living is higher than ever before
in recorded history, psychological
suffering is all around us.
Destructive normality
ACT assumes that the psychological
processes of a normal human mind
are often destructive, and create
psychological suffering for us all,
sooner or later.
Furthermore, ACT postulates that
the root of this suffering is human
language itself. Human language is
a highly complex system of symbols,
which includes words, images, sounds,
facial expressions and physical gestures.
We use this language in two domains:
public and private. The public use of
language includes speaking, talking,
miming, gesturing, writing, painting,
singing, dancing and so on. The private
use of language includes thinking,
imagining, daydreaming, planning,
visualising and so on. A more technical
term for the private use of language is
‘cognition’.
We use this language in two domains:
public and private. The public use of
language includes speaking, talking,
miming, gesturing, writing, painting,
singing, dancing and so on. The private
use of language includes thinking,
imagining, daydreaming, planning,
visualising and so on. A more technical
term for the private use of language is
‘cognition’.
Now clearly the mind is not a ‘thing’
or an ‘object’. Rather, it is a complex
set of cognitive processes—such as
analysing, comparing, evaluating,
planning, remembering, visualising—
and all of these processes rely on
human language. Thus in ACT, the
word ‘mind’ is used as a metaphor for
human language itself.
Unfortunately, human language is a
double-edged sword. On the positive it
helps us make maps and models of the
world; predict and plan for the future;
share knowledge; learn from the past;
imagine things that have never existed,
and go on to create them; develop rules
that guide our behaviour effectively,
and help us to thrive as a community;
communicate with people who are far
away; and learn from people who are
no longer alive.
The dark side of language is that we
use it to lie, manipulate and deceive; to
spread libel, slander and ignorance; to
incite hatred, prejudice and violence; to
make weapons of mass destruction, and
industries of mass pollution; to dwell
on and ‘relive’ painful events from the
past; to scare ourselves by imagining
unpleasant futures; to compare, judge,
criticise and condemn both ourselves
and others; and to create rules for
ourselves that can often be lifeconstricting
or destructive.
Experiential avoidance
ACT rests on the assumption that
human language naturally creates
psychological suffering for us all. One
way it does this is through setting us up
for a struggle with our own thoughts
and feelings, through a process called
experiential avoidance.
Probably the single biggest advantage of human
language was the ability to anticipate
and solve problems. This has enabled
us not only to change the face of the
planet, but to travel outside it.
The
essence of problem-solving is this:
Problem = something we don’t want.
Solution = figure out how to get rid
of it, or avoid it.
This approach obviously works well
in the material world. A wolf outside
your door? Get rid of it. Throw rocks
at it, or spears, or shoot it. Snow, rain,
hail? Well, you can’t get rid of those
things, but you can avoid them, by
hiding in a cave, or building a shelter.
Dry, arid ground? You can get rid of
it, by irrigation and fertilisation, or
you can avoid it, by moving to a better
location. Problem solving strategies
are therefore highly adaptive for us as
humans (and indeed, teaching such
skills has proven to be effective in the
treatment of depression). Given this
problem solving approach works well
in the outside world, it’s only natural
that we would tend to apply it to
our interior world; the psychological
world of thoughts, feelings, memories,
sensations, and urges.
Unfortunately,
all too often when we try to avoid
or get rid of unwanted private
experiences, we simply create extra
suffering for ourselves. For example,
virtually every addiction known to
mankind begins as an attempt to avoid
or get rid of unwanted thoughts and
feelings, such as boredom, loneliness,
anxiety, depression and so on. The
addictive behaviour then becomes self sustaining,
because it provides a quick
and easy way to get rid of cravings or
withdrawal symptoms.
The more time and energy we spend
trying to avoid or get rid of unwanted
private experiences the more we are
likely to suffer psychologically in the
long term. Anxiety disorders provide a
good example. It is not the presence of
anxiety that comprises the essence of
an anxiety disorder. After all, anxiety
is a normal human emotion that we all
experience. At the core of any anxiety
disorder lies a major preoccupation
with trying to avoid or get rid of
anxiety.
OCD provides a florid
example; I never cease to be amazed
by the elaborate rituals that OCD
sufferers devise, in vain attempts to get
rid of anxiety-provoking thoughts and
images. Sadly, the more importance
we place on avoiding anxiety, the
more we develop anxiety about our
anxiety—thereby exacerbating it. It’s
a vicious cycle, found at the centre of
any anxiety disorder. (What is a panic
attack, if not anxiety about anxiety?)
A large body of research shows
that higher experiential avoidance
is associated with anxiety disorders,
depression, poorer work performance,
higher levels of substance abuse,
lower quality of life, high risk sexual
behaviour, borderline personality
disorder, greater severity of PTSD,
long term disability and alexithymia.
Of course, not all forms of
experiential avoidance are unhealthy.
For example, drinking a glass of wine to unwind at night is experiential
avoidance, but it’s not likely to be
harmful. However, drinking an entire
bottle of wine a night is likely to be
extremely harmful, in the long term.
ACT targets experiential avoidance
strategies only when clients use them
to such a degree that they become
costly, life-distorting, or harmful.
ACT calls these ‘emotional control
strategies’, because they are attempts
to directly control how we feel. Many
of the emotional control strategies that
clients use to try to feel good (or to
feel ‘less bad’) may work in the short
term, but frequently they are costly
and self-destructive in the long term.
For example, depressed clients often
withdraw from socialising in order to
avoid uncomfortable thoughts—‘I’m
a burden’, ‘I have nothing to say’, ‘I
won’t enjoy myself ’—and unpleasant
feelings such as anxiety, fatigue, fear of
rejection. In the short term, canceling
a social engagement may give rise to
a short-lived sense of relief, but in
the long term, the increasing social
isolation makes them more depressed.
ACT offers clients an alternative
to experiential avoidance through a
variety of therapeutic interventions.
Therapeutic interventions
In general, clients come to
therapy with an agenda of emotional
control. They want to get rid of their
depression, anxiety, urges to drink,
traumatic memories, low self-esteem,
fear of rejection, anger, grief and so
on. In ACT, there is no attempt to
try to reduce, change, avoid, suppress,
or control these private experiences.
Instead, clients learn to reduce the
impact and influence of unwanted
thoughts and feelings, through the
effective use of mindfulness. Clients
learn to stop fighting with their private
experiences—to open up to them,
make room for them, and allow them
to come and go without a struggle.
The time, energy, and money that they
wasted previously on trying to control
how they feel is then invested in taking
effective action (guided by their values)
to change their life for the better.
Thus ACT interventions focus
around two main processes:
developing acceptance of
unwanted private experiences
which are out of personal control,
commitment and action towards
living a valued life.
What follows is a brief summary
of some core ACT interventions,
illustrated with vignettes of clinical
work with a client called ‘Michael’.
Confronting the agenda
In this step, the client’s agenda
of emotional control is gently and
respectfully undermined, through a process similar to motivational
interviewing. Clients identify the ways
they have tried to get rid of or avoid
unwanted private experiences. They are
then asked to assess for each method:
‘Did this reduce your symptoms in the long
term? What did this strategy cost you, in
terms of time, energy, health, vitality,
relationships? Did it bring you closer to the
life you want?’
‘Michael’ was a 35 year old
accountant who suffered from
significant social anxiety, and had seen a
number of therapists to no avail. On the
first session we ran through the many
strategies he had used to avoid or get
rid of his social anxiety. They included:
drinking alcohol, taking Valium, being
a ‘good listener’ (asking lots of questions,
but sharing little of himself), arriving
late, leaving early, avoiding social events
altogether, deep breathing, relaxation
techniques, using positive affirmations,
disputing negative thoughts, analysing
his childhood, blaming his parents (who
were both socially avoidant), telling
himself to ‘get over it’, self-hypnosis and
so on. Michael realised that none of
these strategies had reduced his anxiety
in the long term. Although strategies
such as taking Valium, drinking
alcohol, and avoiding social events had
reduced his anxiety in the short term,
they had created significant costs to his quality of life. His ‘homework’ was to
notice and write down other emotional
control strategies, and to assess their
long-term effectiveness and costs to his
quality of life.
Control is the problem,
not the solution
In this phase, we increase clients’
awareness that emotional control
strategies are largely responsible for
their problems; that as long as they’re
fixated on trying to control how they
feel, they’re trapped in a vicious cycle of
increasing suffering. Useful metaphors
here include ‘quicksand’, ‘the struggle
switch’, and the concepts of ‘clean
discomfort’ and ‘dirty discomfort’. We
might deliver these metaphors like this:
Remember those old movies
where the bad guy falls into a pool of
quicksand, and the more he struggles,
the faster it sucks him under? In
quicksand, struggling is the worst thing
you can possibly do. The way to survive
is to lie back, spread out your arms, and
float on the surface. It’s tricky, because
every instinct tells you to struggle; but
if you do so, you’ll drown.
The same principle applies to
difficult feelings: the more we try to
fight them, the more they overwhelm
us. Imagine that at the back of our
mind is a ‘struggle switch’. When it’s
switched on, it means we’re going
to struggle against any physical or
emotional pain that comes our way;
whatever discomfort experienced, we’ll
try our best to get rid of it or avoid it.
Suppose the emotion that shows
up is anxiety. If our struggle switch is
ON, then that feeling is completely
unacceptable. This means we could
end up with anger about our anxiety:
‘How dare they make me feel like this?’
Or sadness about our anxiety: ‘Not
again. Why do I always feel like this?’
Or anxiety about our anxiety: ‘What’s
wrong with me? What’s this doing to
my body?’ Or a mixture of all these
feelings. These secondary emotions are
useless, unpleasant, and unhelpful, and
a drain upon our vitality. In response
we get angry, anxious or guilty. Spot
the vicious cycle?
But what if our struggle switch is
OFF? Whatever emotion shows up,
no matter how unpleasant, we don’t
struggle with it. So if anxiety shows up,
it’s not a problem. Sure, it’s unpleasant.
We don’t like it, or want it, but at the
same time, it’s nothing terrible. With
the struggle switch OFF, our anxiety
levels are free to rise and fall as the
situation dictates. Sometimes they’ll
be high, sometimes low and sometimes
there will be no anxiety at all. Far more
importantly, we’re not wasting our time
and energy struggling with it.
Without struggle, we get a natural
level of physical and emotional
discomfort, depending on who we are
and the situation we’re in. In ACT, we
call this ‘clean discomfort’. There’s no
avoiding ‘clean discomfort’. Life serves
it up to all of us in one way or another.
However, once we start struggling
with it, our discomfort levels increase
rapidly. This additional suffering, we
call ‘dirty discomfort’. Our struggle
switch is like an emotional amplifier—
switch it on, and we can have anger
about our anxiety, anxiety about our
anger, depression about our depression,
or guilt about our guilt.
Obviously, these metaphors are
tailored to the particular feelings
the client struggles with. With the
struggle switch ON, not only do we
get emotionally distressed by our own
feelings, we also do whatever we can to
avoid or get rid of them, regardless of
the long term costs. We draw clients’
attention to the many ways they’ve
tried to do this—through more obvious
strategies such as drugs, alcohol, food,
TV, gambling, smoking, sex, surfing
the net—to less obvious emotional
control strategies, such as ruminating,
chastising themselves, blaming others
and so on. (As mentioned earlier, many
control strategies are not an issue, as
long as they are used in moderation.)
Michael was able to connect with
these metaphors readily, especially the
idea of the struggle switch. We were
able to refer back to this in subsequent
sessions whenever he experienced
anxiety. ‘Okay, right now, you’re feeling
anxious. Is the struggle switch on or off?’
Once the emotional control agenda
is undermined, we then introduce the
six core principles of ACT.
Six core principles of ACT
ACT uses six core principles to help
clients develop psychological flexibility:
• defusion;
acceptance;
contact with the present moment;
the Observing Self;
values, and;
committed action.
Each principle has its own specific
methodology, exercises, homework and
metaphors. Take defusion, for example.
In a state of cognitive fusion we are
caught up in language. Our thoughts
seem to be the literal truth, or rules
that must be obeyed, or important
events that require our full attention,
or threatening events that we must get
rid of. In other words, when we fuse
with our thoughts, they have enormous
influence over our behaviour.
Cognitive defusion means we are able
to ‘step back’ and observe language,
without being caught up in it. We
can recognise that our thoughts are
nothing more or less than transient
private events—an ever-changing
stream of words, sounds and pictures.
As we defuse our thoughts, they have
much less impact and influence.
If you look through the wide variety
of writings on ACT, you will find over
a hundred different cognitive defusion
techniques. For example, to deal with
an unpleasant thought, we might
simply observe it with detachment;
or repeat it over and over, out aloud,
until it just becomes a meaningless
sound; or imagine it in the voice of a
cartoon character; or sing it to the tune
of ‘Happy Birthday’; or silently say
‘Thanks, mind’ in gratitude for such an
interesting thought. There is endless
room for creativity. In contrast to CBT,
not one of these cognitive defusion
techniques involves evaluating or
disputing unwanted thoughts.
Here’s a simple exercise in cognitive
defusion for yourself:
Step 1: Bring to mind an upsetting
and recurring negative self-judgment
that takes the form ‘I am X’ such as ‘I
am incompetent’, or ‘I’m stupid.’ Hold
that thought in your mind for several
seconds and believe it as much as you
can. Now notice how it affects you?
Step 2: Now take the thought ‘I am
X’ and insert this phrase in front of it:
‘I’m having the thought that . . .’ Now
run that thought again, this time with
the new phrase. Notice what happens.
In Step 2, most people notice a
‘distance’ from the thought, such that it has much less impact. Notice
there has been no effort to get rid of
the thought, nor to change it. Instead
the relationship with the thought has
changed—it can be seen as just words.
There now follows a brief description
of the six core principles, with reference
to the case of Michael.
1. Cognitive Defusion: learning to
perceive thoughts, images, memories
and other cognitions as what they
are—nothing more than bits of
language, words and pictures—as
opposed to what they can appear to
be—threatening events, rules that must
be obeyed, objective truths and facts.
In session two, Michael, said he
experienced frequent distress from
thoughts such as ‘I’m boring’, ‘I have
nothing to say’, ‘No one likes me’, and ‘I’m
a loser’. As the session continued, I had
Michael interact with these thoughts
in a number of different ways, until
they began to lose their impact. For
example, I had him bring to mind
the thought ‘I’m a loser’, then close his
eyes and notice where it seemed to be
located in space. He sensed it was in
front of him. I asked him to observe
the thought as if he was a curious
scientist, and to notice the form of it:
whether it was more like something he
could see, or something he could hear.
He said it was like words that he could
see, and he noticed that as he ‘looked’
at it, it became less distressing. I asked
him to imagine the thought as words
on a Karaoke screen; then change the
font; then change the colour; then
imagine a bouncing ball jumping from
word to word. By this stage, Michael
was chuckling at the very same thought
that only a few minutes earlier had
brought him to tears. ‘Homework’
included practising several different
defusion techniques with distressing
thoughts—not to get rid of them, but
simply to learn how to step back and
see them for what they are—just ‘bits
of language’ passing through.
2. Acceptance: making room for
unpleasant feelings, sensations,
urges, and other private experiences;
allowing them to come and go without
struggling with them, running from
them, or giving them undue attention.
In session three, I asked Michael to
make himself anxious by imagining
himself at a forthcoming office
party. When I asked him to scan his
body and notice where he felt the
anxiety most intensely he reported a
‘huge knot’ in his stomach. I asked
him to observe this sensation as if
he was a curious scientist who had
never seen anything like it before; to
notice the edges of it, the shape of it,
the vibration, weight, temperature,
pulsation, and the myriad of other
sensations within the sensation. I had
him breathe into the sensation, and
‘make room for it’; to allow it to be
there, even though he did not like it or
want it. Michael soon reported a sense
of calmness; a sense of being at ease
with his anxiety, even though he didn’t
like it. ‘Homework’ included practising
this technique with his recurrent
feelings of anxiety—not to get rid of
them, but simply to learn how to let
them come and go without a struggle.
3. Contact with the present moment:
bringing full awareness to your here and-now
experience, with openness,
interest, and receptiveness; focusing on,
and engaging fully in whatever you are
doing.
In session four, I took Michael
through a simple mindfulness exercise,
focused on the experience of eating.
I gave him a sultana, and asked him
to eat it ‘in slow motion’, with a total
focus on the taste and texture of the
fruit, and the sounds, sensations and
movements inside his mouth. I told
him, ‘While you’re doing this, all sorts
of distracting thoughts and feelings
may arise. The aim is simply to let
your thoughts come and go, and allow
your feelings to be there, and keep your
attention focused on eating the sultana.’
Afterwards, Michael said he was
amazed that there was so much flavour
in one single sultana. I was then able
to use this experience to draw an
analogy with social situations, where
Michael would be so caught up in his
thoughts and feelings that he wasn’t
able to engage fully in conversation,
and missed out on the ‘richness’.
‘Homework’ included practising
full engagement with all the five
senses in a number of daily routines
(having a shower, brushing his teeth,
and washing the dishes) as well as
continuing to practise his defusion and
acceptance techniques. He agreed also
to practice mindful engagement in
conversations; i.e. keeping his attention
on the other person, rather than on his
own thoughts and feelings.
4. The Observing Self: accessing a
transcendent sense of self; a continuity
of consciousness that is unchanging,
ever-present, and impervious to harm.
From this perspective, it is possible to
experience directly that you are not
your thoughts, feelings, memories,
urges, sensations, images, roles, or
physical body. These phenomena
change constantly and are peripheral
aspects of you, but they are not the
essence of who you are.
In session five, I took Michael
through a mindfulness exercise
designed to have him access this
transcendent self. First, I asked him to
close his eyes and observe his thoughts:
the form they took, their apparent
location in space, the speed with which
they were moving. Then I asked him:
‘Be aware of what you are noticing.
There are your thoughts, and there is you
noticing them. So there are two processes
going on—a process of thinking, and a
process of observing that thinking.’ Again
and again, I drew his attention to
the distinction between the thoughts
that arise, and the self who observes
those thoughts. From the perspective
of this Observing Self, no thought is
dangerous, threatening, or controlling.
5. Values: clarifying what is most
important, deep in your heart; what
sort of person you want to be; what is
significant and meaningful to you; and
what you want to stand for in this life.
In session six, Michael identified
important values around connecting
with others, building meaningful
friendships, developing intimacy,
and being authentic and genuine. We
discussed the concept of willingness.
The willingness to feel anxiety doesn’t
mean you like or want it. Instead
it means you allow it to be there in
order to do something you value. I
asked Michael, ‘If taking your life in the
direction of these values means you need to
make room for feelings of anxiety, are you
willing to do that?’ His reply was ‘Yes.’
6. Committed Action: setting goals,
guided by your values, and taking
effective action to achieve them.
Continuing session six, we moved
to setting goals in line with Michael’s
values. Initially, he set the goal of going for lunch with a work colleague
every day, and sharing some personal
information on each occasion. In
subsequent sessions, he set increasingly
challenging social goals, and continued
to practice mindfulness skills to handle
the anxious thoughts and feelings
that inevitably arose. At the end of
ten sessions, Michael reported that
he was socialising a lot more, and
more importantly, he was enjoying it.
Thoughts of being ‘a loser’ or ‘boring’ or
‘unlikeable’ still occurred, but usually
he did not take them seriously or pay
them any attention. Likewise, feelings
of anxiety still occurred in many social
situations, but no longer bothered him
or distracted him. Overall, his anxiety
levels had diminished considerably.
This reduction in anxiety was not the
goal of therapy, but was a pleasant
by-product. This illustrates how ACT
can result in good symptom reduction
without ever aiming for it. First, a lot
of exposure took place, as Michael
engaged in increasingly challenging
social situations. It is well known that
exposure frequently can lead to reduced
anxiety. Second, the more accepting
Michael became of his unwanted
thoughts and feelings, the less
anxiety he had about those thoughts
and feelings. Indeed, practising
mindfulness of unwanted thoughts and
feelings is a form of exposure in itself.
The ACT therapeutic relationship
ACT training helps therapists
to develop the essential qualities of
compassion, acceptance, empathy,
respect, and the ability to stay
psychologically present even in the
midst of strong emotions. Furthermore,
ACT teaches therapists that, thanks
to human language, they are in the
same boat as their clients—so they
don’t need to be enlightened beings or
to ‘have it all together’. In fact, they
might say to their clients something
like: ‘I don’t want you to think I’ve got
my life completely in order. It’s more as if
you’re climbing your mountain over there
and I’m climbing my mountain over here.
It’s not as if I’ve reached the top and I’m
having a rest. It’s just that from where I
am on my mountain, I can see obstacles on
your mountain that you can’t see. So I can
point those out to you, and maybe show
you some alternative routes around them.’
Conclusion
The experience of doing therapy
becomes vastly different with ACT. It
is no longer about getting rid of bad
feelings or getting over old trauma.
Instead it is about creating a rich, full
and meaningful life.
This is confirmed
by the findings of Strosahl, Hayes,
Bergan and Romano (1998) who
showed that ACT increases therapist
effectiveness and Hayes et al (2004)
who showed that it reduces burnout. If
I had to summarise ACT on a t-shirt,
it would read: ‘Embrace your demons,
and follow your heart.’
References
Bach, P. & Hayes, Steven C. (2002). The
use of Acceptance and Commitment
Therapy to prevent the rehospitalisation
of psychotic patients: a randomized
controlled trial. Journal of Consulting and
Clinical Psychology, 70, 1129–1139.
Bond, F. W. & Bunce, D. (2000). Mediators
of change in emotion-focused and problemfocused
worksite stress management
interventions. Journal of Occupational
Health Psychology, 5, 156-163.
Branstetter, A. D., Wilson, K. G.,
Hildebrandt, M., & Mutch, D. (2004).
Improving psychological adjustment
among cancer patients:ACT and CBT.
Paper presented at the Association for
Advancement of Behavior Therapy, New
Orleans.
Chiles J., and Strosahl, K. (1995),
The Suicidal Patient: Principles Of
Assessment, Treatment, and Case
Management, American Psychiatric Press,
Washington, DC.
Dahl, J., Wilson, K. G., & Nilsson, A.
(2004). Acceptance and commitment
therapy and the treatment of persons at
risk for long-term disability resulting from
stress and pain symptoms: A preliminary
randomized trial. Behavior Therapy, 35,
785–802.
Davies, T. (1997), ABC of Mental Health,
British Medical Journal, 314, 27.5.97:
1536–39.
Hayes, S. C., Bissett, R., Roget, N.,
Padilla, M., Kohlenberg, B. S., Fisher, G.,
et al. (2004). The impact of acceptance
and commitment training on stigmatizing
attitudes and professional burnout of
substance abuse counselors. Behavior
Therapy, 35, 821–836.
Kessler, R.C., McGonagle, K.A., Zhao,
S., Nelson, C.B., Hughes, M., Eshleman,
S., Wittchen, H.U., and Kendler, K.S.
(1994), Lifetime and 12-month Prevalence
of DSM-III-R Psychiatric Disorders in
the United States, Archives of General
Psychiatry, 51 (Jan 1994): 8–19.
Strosahl, K. D., Hayes, S. C., Bergan, J.,
& Romano, P. (1998). Does field based
training in behavior therapy improve
clinical effectiveness? Evidence from the
Acceptance and Commitment Therapy
training project. Behavior Therapy, 29,
35–64.
Twohig, M. P., Hayes, S. C., Masuda,
A. (2006). Increasing willingness to
experience obsessions: Acceptance and
Commitment Therapy as a treatment for
obsessive compulsive disorder. Behavior
Therapy, 37:1, 3–13.
Zettle, R. D., & Raines, J. C. (1989).
Group cognitive and contextual therapies
in treatment of depression. Journal of
Clinical Psychology, 45, 438-445.
